Evergreen Crossing And The Lofts
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 5404 Georgetown Road, Indianapolis, Indiana 46254
- CMS Provider Number
- 155826
- Inspections on file
- 42
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Evergreen Crossing And The Lofts during CMS and state inspections, most recent first.
The facility failed to maintain accurate reconciliation and accountability of controlled drugs across multiple units, leading to diversion of at least 60 hydrocodone-acetaminophen tablets for a resident. Pharmacy records showed four cards of narcotics were received, but later two cards were missing from the cart while the narcotic count still appeared correct. A resident was found unresponsive and later pronounced dead, and subsequent review revealed missing pages from the narcotic count book, a newly started count sheet, and incomplete two-nurse signatures on shift change inventory trackers. An LPN admitted starting a new narcotic count sheet based only on the remaining medications in the cart, contrary to facility policies requiring double-locked storage, two-nurse shift counts, complete documentation, and timely removal and destruction of controlled substances after discharge or death.
A resident with severe chronic pain and multiple musculoskeletal diagnoses had an order for Norco, with four full cards of medication received from the pharmacy. After the resident was found unresponsive and later pronounced dead, two full cards (60 tablets) of Norco were discovered missing from the med cart. Staff identified that a narcotic count page was missing from the narcotic book and a new count sheet had been started, allowing counts to appear correct despite the missing cards. The resident’s narcotic count sheet continued to be signed for days after death, and the narcotics were not promptly removed from the cart for DON destruction. Review of narcotic tracking sheets across multiple med carts showed that required two-nurse signatures for adding or removing controlled drug cards and count sheets were often missing, reflecting a broader failure to maintain accurate controlled drug counts and chain of custody.
Surveyors found that medications were left unattended at a resident's bedside without a physician's order for self-administration, and a utility cart with hazardous painting supplies was left unsupervised in a hallway near a resident with severe cognitive impairment. Facility policies prohibited these practices, but staff failed to follow them, creating potential accident hazards.
Three residents with diabetes did not receive insulin in accordance with physician orders or manufacturer instructions. Insulin was often administered after meals instead of before, and staff did not consistently notify providers of high blood sugar readings or update care plans. Nursing staff cited workload and resident availability as reasons for delayed or improperly timed insulin administration, leading to significant medication errors.
A resident with multiple risk factors developed a severe unstageable pressure ulcer and a Deep Tissue Injury (DTI) on the heel due to the facility's failure to consistently identify, assess, document, and communicate about wounds. Staff did not perform or document required skin assessments, failed to update care plans, and did not notify the primary care provider or the resident's representative in a timely manner, resulting in the progression of wounds and the need for surgical debridement.
A resident with multiple complex conditions developed new and worsening wounds, including pressure ulcers and a DTI, but the care plan was not promptly or adequately updated to reflect changes in wound management. Physician orders and wound assessments documented the progression of wounds and new interventions, but these were not consistently incorporated into the care plan, and some wounds were not identified or documented in a timely manner. Staff interviews and audits revealed inconsistent execution of care plan updates and documentation.
The facility failed to create comprehensive care plans for two residents, leading to deficiencies in addressing their specific needs. A resident with a history of cerebral amyloid angiopathy and dementia exhibited wandering behaviors and a strong desire to ride his bicycle, which was not addressed in his care plan. Another resident admitted with a trans metatarsal amputation lacked a care plan addressing this condition. The facility's care planning process did not adequately accommodate the residents' individual needs and preferences.
The facility failed to update care plans for two residents, one with chewing difficulties due to poorly fitting dentures and another refusing pressure-relieving boots. The care plans lacked necessary interventions, and there was no specific policy for care plan revision.
The facility failed to prevent potential accidents by not ensuring call lights were within reach for three residents, leading to increased fall risk and inadequate supervision. A resident with paralysis had her call light out of reach, resulting in falls and unidentified pills at her bedside. Another resident, admitted for rehab after a back fracture, fell due to an inaccessible call light, with incomplete neurological assessments. A third resident, with limited arm mobility, couldn't reach her call light, expressing fear of falling. Facility policies on fall prevention and resident rights were not followed.
A resident without teeth or dentures experienced significant weight loss due to the facility's failure to provide appropriate nutritional support. Despite having conditions like hemiplegia and dysphagia, the resident was served hard-to-chew foods and did not consistently receive preferred nutrition supplements. Inconsistent weight monitoring and lack of meal assistance further contributed to the resident's nutritional deficiency.
The facility failed to follow medication administration protocols for three residents, leading to unnecessary drug administration. A resident received metoprolol despite low blood pressure readings, another did not receive midodrine when needed, and a third was given hydralazine without blood pressure checks. The President of Risk Management noted staff misunderstanding of orders.
The facility failed to date multi-dose vials of tuberculin serum and remove expired insulin pens from storage. A vial of Aplisol in the medication room refrigerator and a vial of Tubersol in another refrigerator were found without opening dates. Two insulin pens belonging to a resident were not removed after 30 days, as confirmed by an LPN. The facility's policy requires expiration dates to be determined by the pharmacist and specifies shorter expiration dates for certain medications once opened.
The facility failed to notify the physician of changes in condition for two residents who developed new pressure ulcers. One resident with dementia and COPD had an unstageable ulcer, and another with hypertension and peripheral vascular disease had a stage 3 ulcer. In both cases, the physician was not informed, despite the facility's policy requiring notification for changes in condition.
A facility failed to prevent a new pressure ulcer and ensure timely treatment for a resident with a history of pressure ulcers. The resident, dependent on staff for care, developed an unstageable pressure ulcer that worsened due to lack of timely assessment and intervention. The facility did not notify the physician of the change in condition, and the wound deteriorated into a stage IV ulcer with severe complications.
The facility failed to ensure accurate medication quantities were provided at discharge for two residents, resulting in incomplete discharge instructions. One resident's form lacked quantities for three medications, while another's form lacked quantities for multiple medications. The facility's policy requires documentation of medication name, dose, and quantity, which was not followed.
Failure to Maintain Accurate Controlled Drug Accountability Resulting in Narcotic Diversion
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective system for reconciliation and accountability of controlled medications on all four nursing units, which resulted in diversion of at least 60 hydrocodone-acetaminophen (Norco) tablets from one unit. A facility reported incident documented that two cards of a resident’s hydrocodone-acetaminophen, totaling 60 tablets, were discovered missing from the medication cart. A pharmacy packing slip showed that four cards (120 tablets) of hydrocodone-acetaminophen had been received for this resident and signed for by an RN. A progress note recorded that the resident was found unresponsive at 6:00 a.m., CPR was initiated but unsuccessful, and the resident was pronounced dead at 6:15 a.m. Staff statements and records revealed discrepancies and irregularities in the narcotic count process. One LPN reported last seeing the resident’s hydrocodone-acetaminophen at the end of her shift and, upon returning to work, noted that two cards were missing even though the narcotic count was documented as correct. A narcotic count sheet for the same medication was later signed as having 45 tablets nearly three weeks after the resident’s death. Review of Shift Change/Controlled Substance Inventory Tracker sheets from all six medication carts across the four units showed that two nurses had not consistently signed as required when controlled medication cards and count sheets were added or removed, contrary to the instructions on the forms and facility policy. Further investigation identified that a page was missing from the narcotic count book, which was numbered sequentially, and that a new count page had been started. An LPN who had worked the evening shift before the discrepancy reported that narcotic counts between evening and night shift had been correct, but the night shift nurse only had the new narcotic sheet to reference and was unaware that cards were missing. Another nurse questioned the reduced number of medication cards the following morning. The LPN involved denied that extra cards had been present in the cart but later admitted to starting a new narcotic count sheet, claiming the original sheet was already missing and that the new count was based solely on the medications present in the cart. The facility’s own policies required double-locked storage, accurate shift-to-shift counts by two nurses, proper documentation of controlled drug cards and count sheets, immediate reporting and investigation of discrepancies, and timely removal and destruction of controlled substances after discharge or death, but these procedures were not followed, contributing to the diversion and inaccurate accounting of controlled medications.
Failure to Safeguard and Accurately Account for Controlled Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s controlled medications from diversion and to maintain accurate narcotic accountability. A resident with diagnoses including cervical radiculopathy, fibromyalgia, carpal tunnel syndrome, and lumbar disc degeneration had a physician’s order for hydrocodone-acetaminophen (Norco) 5-325 mg, one tablet by mouth every six hours for pain. A pain assessment documented that the resident verbalized severe pain. A pharmacy packing slip showed that a nurse signed for receipt of four cards of 30 Norco tablets (total 120 tablets) for this resident. The resident was later found unresponsive at 6:00 a.m., CPR was initiated but unsuccessful, and the resident was pronounced dead at 6:15 a.m. Subsequently, two full cards of the resident’s Norco, totaling 60 tablets, were discovered missing from the medication cart. A nurse reported that she had last seen the resident’s Norco cards at the end of her shift prior to the discovery, and when she returned to work she noted that two cards were missing even though the narcotic count matched the narcotic count sheets. Staff interviews revealed that the narcotic count sheet for this resident was altered: a page was missing from the narcotic count book, the pages of which were numbered sequentially, and a new narcotic count sheet had been started. The night-shift nurse had only the new narcotic sheet to reference and was unaware that additional cards should have been present. The nurse suspected of involvement admitted starting a new narcotic count sheet but denied removing the original page or taking the missing narcotics. The facility’s records further showed that a narcotic count sheet for the resident’s Norco was still being signed as having 45 tablets nineteen days after the resident’s death, indicating that the medication remained on the cart well beyond the time of death. Staff interviews indicated that, per facility practice and policy, the DON was responsible for destruction of narcotic medications after a resident’s discharge or death, and that narcotics were not to be destroyed by hallway nurses. There was also a delay in removing and destroying the resident’s narcotics from the cart. Review of shift change/controlled substance inventory tracker sheets from all six medication carts showed that two nurses had not consistently signed as required when narcotic cards and count sheets were added or removed, contrary to facility policy that required two-nurse verification of controlled drug counts, cards, and count sheets at each shift change. These actions and inactions resulted in 60 missing Norco tablets and demonstrated a failure to safeguard the resident’s narcotic medications from diversion and to maintain proper chain of custody and documentation.
Failure to Secure Medications and Hazardous Materials
Penalty
Summary
Surveyors observed that the facility failed to secure medications, painting supplies, and hazardous chemicals, resulting in potential accident hazards for residents. In one instance, a resident with moderately impaired cognition and multiple medical conditions, including osteomyelitis, respiratory failure, and dependence on renal dialysis, was found with unidentified pills left unattended at his bedside on multiple occasions. The resident stated that staff routinely left medications for him to take at his discretion, and there was no physician's order or care plan authorizing self-administration of medications. Facility policy explicitly prohibited leaving medications unattended or at the bedside. Additionally, a utility cart containing painting supplies and hazardous chemicals, such as wall putty, caulking, paint remover, cleaner/degreaser sprays, and open buckets of paint, was left unsupervised in a hallway near a resident's room. This resident, who had severe cognitive impairment, autistic disorder, unspecified dementia, and intellectual disabilities, was observed wandering unsupervised and stopping near the cart for extended periods. Staff confirmed the resident's confusion and tendency to wander. Facility policy required hazardous materials to be handled and stored safely, but the cart was not secured as required.
Failure to Administer Insulin per Physician Orders and Manufacturer Instructions
Penalty
Summary
Surveyors identified that the facility failed to ensure insulin was administered in accordance with physician's orders and manufacturer instructions for three residents observed for insulin administration. For one resident with type 2 diabetes and a history of hyperglycemia and ketoacidosis, insulin was routinely administered after meals instead of before meals as ordered. The resident repeatedly complained to staff about high blood sugar readings, delayed insulin administration, and lack of timely physician notification for additional insulin coverage. Documentation showed that blood sugar readings were frequently elevated, with only sporadic documentation of physician notification for extremely high readings. The resident's care plan was not updated after admission, and there were lapses in providing a replacement for his continuous glucose monitoring device. Another resident with type 2 diabetes and diabetic neuropathy was observed receiving Lantus insulin after finishing breakfast, rather than at the prescribed time. The resident's orders required blood glucose testing before meals and timely administration of insulin, but observations and record reviews indicated that insulin was not consistently administered as ordered. Similarly, a third resident with type 2 diabetes was observed receiving Lantus insulin after her blood sugar was checked, with staff indicating that insulin was given according to resident preference or when breakfast trays were served, rather than strictly following the prescribed timing. Interviews with nursing staff revealed inconsistent practices regarding the timing of insulin administration, with some staff prioritizing convenience or resident requests over adherence to physician orders and manufacturer guidelines. Staff also reported challenges in locating residents at medication times and managing multiple diabetic residents, which contributed to delays and deviations from prescribed protocols. Facility policies required medications to be administered as prescribed and at the right time, but these were not consistently followed, resulting in significant medication errors for the residents involved.
Failure to Identify, Assess, and Communicate Pressure Ulcers Resulting in Harm
Penalty
Summary
The facility failed to properly identify, assess, and document wounds for a resident with significant risk factors, resulting in the development and progression of pressure ulcers. The resident, who had a history of hemiplegia, diabetes with neuropathy, Parkinson's disease, and was bedfast with limited mobility, was admitted without skin issues but later developed skin breakdown on the buttocks that progressed to an unstageable pressure ulcer requiring surgical debridement. There was also a failure to assess and treat a Deep Tissue Injury (DTI) on the right heel, which was not identified or documented until brought to staff attention by the resident's representative. Staff did not consistently perform or document weekly skin assessments as ordered, and there were discrepancies in wound identification, staging, and communication among nursing staff, wound care providers, and the primary care physician. Documentation was lacking regarding the identification, measurement, and treatment of wounds, as well as notification of the primary care physician and the resident's representative. The care plan was not updated in a timely manner to reflect the resident's changing skin condition, and interventions such as the use of a low air loss mattress and offloading devices were not consistently implemented or documented. The resident's representative was not kept informed about the extent or severity of the wounds, leading to distress when she discovered the wounds herself. Interviews with staff revealed confusion about roles and responsibilities for wound documentation, notification, and care planning. There were also inconsistencies in the documentation of wound locations and descriptions, and a lack of follow-up on wounds identified during hospitalizations. The facility's failure to identify, assess, and communicate about wounds resulted in harm to the resident, including the need for surgical intervention.
Failure to Update and Personalize Wound Care Plans
Penalty
Summary
The facility failed to ensure that care plan interventions for a resident with multiple complex medical conditions were personalized, implemented, and updated to reflect changes in wound management. The resident had a history of hemiplegia and hemiparesis following a stroke, type 2 diabetes mellitus with neuropathy, Parkinson's disease, encephalopathy, and dysphagia. The initial care plan identified risks for altered skin integrity and included general interventions such as skin assessments, weekly skin checks, and the use of off-loading devices. However, as the resident developed new and worsening wounds, including a full-thickness dermatosis and unstageable pressure ulcers, the care plan was not promptly or adequately updated to address these changes. Physician orders and wound assessments documented the progression of the resident's wounds, including the development of a new full-thickness dermatosis, an unstageable pressure ulcer on the coccyx, and a deep tissue injury (DTI) on the right heel. Orders for specific wound care treatments, such as the application of Triad cream, medical grade honey, and the use of a low air loss mattress, were issued as the resident's condition changed. Despite these changes, the care plan did not consistently reflect the updated interventions or the evolving clinical picture. Documentation also revealed that some wounds were not identified or documented in a timely manner, and there was a lack of detailed information regarding the acquisition, description, and management of certain wounds. Interviews with facility staff indicated that the responsibility for updating care plans in response to new or worsening wounds was not clearly defined or consistently executed. Audits conducted by facility management revealed that a significant proportion of residents with wounds required care plan updates, and that some skin issues were undocumented. The facility's policies required individualized care plans, communication of risk factors and interventions, and ongoing evaluation and modification of care plans, but these practices were not consistently followed for the resident in question.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive and individualized care plans for two residents, leading to deficiencies in addressing their specific needs. Resident 88, who had a history of cerebral amyloid angiopathy, alcohol abuse, and unspecified dementia, exhibited behaviors related to wandering and expressed a strong desire to ride his bicycle, which was not addressed in his care plan. Despite being assessed as at risk for elopement, his care plan lacked person-centered interventions to accommodate his cycling hobby and fitness enthusiasm, resulting in ongoing agitation and wandering behaviors. The staff, including the Social Service Director and LPN, were unsure of how to manage his behaviors effectively, and his care plan was not updated to reflect his preferences or address his irritation about not being able to ride his bike. Additionally, the facility failed to implement a comprehensive care plan for Resident 196, who was admitted with a trans metatarsal amputation (TMA) and other significant medical conditions such as end-stage renal disease and major depressive disorder. The care plan for Resident 196 did not include a problem statement or interventions related to his TMA, indicating a lack of individualized care planning for his specific medical needs. The President of Risk Management confirmed the absence of a care plan for TMA, highlighting a gap in the facility's care planning process.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to reassess the effectiveness of interventions and revise the care plans for two residents, leading to deficiencies in their care. Resident 28, who has hemiplegia and dysphagia, reported difficulty chewing due to poorly fitting dentures and a mechanically altered diet. Despite a care plan revision, there was no documentation of interventions addressing her complaints about chewing and swallowing difficulties. Her care plan was not updated to reflect her dietary needs, and she continued to receive a regular texture diet, which she found difficult to chew, causing discomfort. Resident 241, diagnosed with sepsis and open wounds, was recommended to wear pressure-relieving boots while in bed. However, he consistently refused to wear them, as documented in multiple notes. Despite this ongoing refusal, his care plan did not include interventions to address his refusal or provide guidance for staff on how to manage the situation. The facility also lacked a specific policy related to care plan revision, as confirmed by a registered nurse, which contributed to the oversight in updating the care plans appropriately.
Failure to Ensure Call Light Accessibility and Supervision
Penalty
Summary
The facility failed to prevent potential accidents by not ensuring that call lights were within reach for three residents, leading to increased risk of falls and inadequate supervision. Resident 10, who had left-sided paralysis after a stroke, was observed with her call light on the floor, out of reach, on multiple occasions. This resident had a history of falls, including an unwitnessed fall resulting in a fracture, and was found with unidentified pills at her bedside, which should not have been there according to her care plan. Resident 142, who was admitted for rehabilitation after a back fracture, also had her call light out of reach, leading to a fall when she attempted to transfer herself to the bathroom. Despite interventions to remind her to ask for help, the call light was not consistently placed within her reach, contributing to her falls. Neurological assessments for her falls were incomplete, indicating a lack of thorough follow-up. Resident 15, who had limited arm mobility, was unable to reach her call light, which was often misplaced or hidden. She expressed fear of falling due to her awkward positioning in bed and the absence of her call light within reach. The facility's policies on fall prevention and resident rights were not adhered to, as evidenced by the repeated failure to ensure call lights were accessible, increasing the risk of accidents and compromising resident safety.
Failure to Provide Adequate Nutritional Support for Resident Without Dentures
Penalty
Summary
The facility failed to provide adequate nutritional support for a resident without teeth or dentures, leading to significant weight loss. The resident, who had no natural teeth and lacked dentures, was observed struggling to eat the meals provided, which included hard-to-chew items like fried catfish, chicken wings, and tater tots. Despite expressing a preference for softer foods like Glucerna shakes, these were not consistently provided. The resident's inability to chew the food led to a noticeable weight loss of 11 percent over six months. The resident's medical history included hemiplegia and dysphagia, conditions that necessitate careful dietary management. Despite a speech therapy evaluation and an upgrade to a regular diet, the resident continued to experience difficulty chewing and swallowing. The facility's records showed inconsistent weight monitoring, with the resident not being weighed weekly as recommended after significant weight loss was noted. The resident's weight fluctuated, indicating instability, and no new interventions were implemented despite ongoing weight loss. Interviews with staff revealed a lack of consistent support for the resident during meals. The resident was supposed to receive assistance with meal setup, including cutting food into manageable pieces, but this was not consistently done. Additionally, the facility lacked policies for nutrition management and weight loss management, which contributed to the oversight in addressing the resident's nutritional needs effectively.
Failure to Adhere to Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to medication administration protocols for three residents, leading to the administration of unnecessary drugs. Resident 196, who had diagnoses including end-stage renal disease and hypertension, was prescribed metoprolol succinate with specific parameters to hold the medication if systolic blood pressure was less than 110 or pulse was less than 60. Despite these instructions, the medication was administered on multiple occasions when the resident's blood pressure was below the specified threshold, and on several other occasions, the blood pressure was not checked prior to administration. Similarly, Resident 59, with conditions such as end-stage renal disease and dementia, had an order for midodrine to be given if systolic blood pressure was less than 110. However, the medication was not administered when her blood pressure was below this level. Resident 195, diagnosed with end-stage renal disease and heart failure, was prescribed hydralazine with instructions to hold the medication if systolic blood pressure was less than 110. The medication was administered without checking blood pressure on several occasions. The President of Risk Management indicated that staff did not understand the orders, highlighting a failure in executing physician orders as per the facility's policy.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to properly label and manage medications, specifically multi-dose vials of tuberculin serum and insulin pens. During an observation, a vial of Aplisol (tuberculin serum) in the Health unit medication room refrigerator was found without a date indicating when it was opened. Additionally, Health unit medication cart number 2 contained two insulin pens belonging to a resident, with one Semglee (insulin) pen and one Lispro (insulin) pen, both opened on specific dates but not removed after 30 days as required. Another vial of Tubersol (tuberculin serum) in the Heritage unit medication room refrigerator also lacked an opening date. An LPN confirmed that insulin pens are only effective for 30 days after opening. The facility's policy on medication storage, provided by the President of Risk Management, specifies that expiration dates should be determined by the pharmacist and that certain medications require a shorter expiration date once opened to maintain purity and potency.
Failure to Notify Physician of Pressure Ulcer Development
Penalty
Summary
The facility failed to notify the physician of changes in the condition of two residents, Resident B and Resident D, regarding the development of new pressure ulcers. Resident B, who had diagnoses including unspecified dementia, COPD, and hypertensive heart disease, was found to have a new unstageable pressure ulcer on 10/18/24. Although the wound team and family were notified, there was no documentation that the physician was informed of this change. A subsequent consult on 10/22/24 confirmed the presence of the new pressure injury, but the lack of physician notification was noted during an interview with the Regional Clinical Support. Resident D, with diagnoses including hypertension, hyperlipidemia, and peripheral vascular disease, developed a stage 3 pressure ulcer. A nurse's progress note from 9/7/24 indicated the presence of a stage 2 wound, and the wound care team was notified, but there was no documentation of physician or family notification. An observation on 11/15/24 revealed the ulcer had worsened, with a large red open area and blood drainage. The facility's policy on notification of change of condition was not followed, as the physician was not informed of the new pressure ulcer development.
Failure to Prevent and Timely Treat Pressure Ulcer
Penalty
Summary
The facility failed to prevent the development of a new pressure ulcer for a resident with a history of pressure ulcers and did not ensure timely assessment and treatment of the new pressure ulcer. Resident B, who was totally dependent on staff for all care needs, was observed with a pressure ulcer on her lower sacrum/coccyx area. Despite being compliant with care protocols, the resident developed a new unstageable pressure ulcer, which was not promptly addressed by the facility staff. The resident's medical record indicated a lack of documentation regarding the refusal of care, incontinent check/change care, turning or repositioning, offloading procedures, and other interventions to prevent skin breakdown. The facility's failure to notify the physician of the resident's change in skin condition and the absence of a temporary treatment plan contributed to the worsening of the wound. The wound, initially found by nursing staff, was not assessed by the Wound Nurse Practitioner until several days later, leading to a significant deterioration in the resident's condition. The facility's policies on skin care and wound management, as well as notification of change of condition, were not consistently followed. The resident's wound worsened significantly, resulting in a stage IV pressure ulcer with severe complications, including sepsis and a multifocal infection. The lack of timely intervention and communication among the facility staff and healthcare providers contributed to the resident's deteriorating condition and the development of a severe pressure ulcer.
Failure to Provide Accurate Medication Quantities at Discharge
Penalty
Summary
The facility failed to ensure that residents' discharge instructions accurately reflected their reconciled medications, resulting in residents being sent home without an accurate quantity of medications. For Resident B, who had diagnoses including peripheral vascular disease, type 2 diabetes, hyperlipidemia, morbid obesity, right above knee amputation, and polyneuropathy, the medication discharge form lacked the quantity of three medications: Ozempic, NovoLog pen, and insulin glargine solution. Resident B was discharged to the community on 2/1/24. Similarly, Resident D, who had diagnoses including type 2 diabetes, hemiplegia, cerebral infarction, hyperlipidemia, constipation, polyneuropathy, and hypertension, was discharged to the community on 1/31/24. The medication discharge form for Resident D listed the medication names and directions but lacked the quantity for multiple medications, including clopidogrel, Lantus, multivitamin, Ozempic, pantoprazole, miralax, sodium chloride spray, zinc, acetaminophen, amlodipine, ascorbic acid, carvedilol, ibuprofen, and vitamin D. During an interview, the Executive Director indicated that residents are sent home with all their medications unless they leave against medical advice, in which case they receive three days of medications. The facility's policy on medications upon discharge requires documentation of the name, dose, and quantity of medications sent with the resident, which was not followed in these cases.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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