Above 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 Forest Creek Village during CMS and state inspections, most recent first.
Care plans for two residents were not revised to match their documented code status. Both residents had active physician orders and POST forms indicating DNR, but their care plans initially listed them as full code before later entries noted DNR. The Administrator stated the care plans should have reflected only the current DNR preferences.
A resident with chronic pain and neuropathy, documented as cognitively intact, was found with two pill cups left on the dresser in the room, one labeled with the resident's name and one unlabeled. An LPN confirmed the cups contained the resident's prescribed medications, including melatonin 5 mg and gabapentin 300 mg and 600 mg, and acknowledged they should not have been left there. Review of the record showed active physician orders for these medications but no self-medication administration assessment or physician order authorizing the resident to self-administer, despite facility policy requiring both before allowing self-administration.
Surveyors found that three resident rooms were not maintained in a clean and sanitary condition. In one room, a full urinal with dark yellow urine was left on the floor for several days. In another, the bathroom had a strong urine and feces odor, dried feces on the toilet bowl and seat, and trash cans without liners that contained feces-soiled toilet paper and a urine-soiled brief; a CNA acknowledged the cans should have been lined and emptied and housekeeping notified. In a third room, a resident reported placing a folded hospital blanket on the bathroom floor to address a leaking toilet, resulting in a dark brown–stained blanket that staff stated was changed about weekly and should not have been left on the floor.
The facility failed to maintain an effective pest control program when roach-like insects were observed in two resident rooms. In one room, a meal tray from the prior evening with leftover food and an open pudding cup remained on a dresser, and a roach-like insect was seen crawling out of the food while the resident reported not having seen a roach for about a week. In another room, a roach-like insect was seen crawling up the bathroom wall under the sink. A prior pest control report documented cockroaches in resident rooms and hallways and noted that clutter and stored items in most rooms limited access for service, despite a facility policy stating it would maintain an effective pest control program so the facility is free of pests.
An Activity Assistant took a photo of a cognitively impaired resident and posted it on social media with an inappropriate caption, without authorization from the family or facility, violating policies on mental abuse and confidentiality.
Surveyors observed a buildup of dark substance, dust, debris, a screwdriver, and plastic lids under a kitchen freezer, as well as dust and debris under dry storage shelves. The dietary supervisor confirmed these areas should have been cleaned, and facility policy requires kitchen floors to be kept clean and sanitary.
A resident with multiple comorbidities and a history of falls was found with their bed not in the lowest position, despite care plan interventions and a physician's order requiring it. A QMA confirmed the bed should not have been left elevated, and facility policy mandates implementation of person-centered care plans.
Two residents received meals that were not at a palatable or proper temperature, with one resident unable to cut her sausage and reporting cold food, and another resident leaving half her meal uneaten due to it not being hot. Both residents indicated this was a recurring issue, and food was observed sitting in the hallway before delivery, contrary to facility policy.
Staff failed to follow enhanced barrier precautions for a resident with an indwelling urinary catheter during a transfer. An LPN wore gloves but not a gown, and a CNA wore neither gloves nor a gown, despite facility policy and the resident's care plan requiring both gown and gloves for such high-contact care activities.
A buildup of a thick, black, tar-like substance mixed with hair and debris was observed along the floorboards and trim in a hallway. The DON confirmed this should have been removed during regular cleaning, and the Housekeeping Supervisor stated that staff are expected to scrape such buildup daily. The facility could not provide a related policy during the survey.
A resident with minimal cognitive impairment and multiple diagnoses was found with a senna tablet at their bedside without a completed self-medication administration assessment, as required by facility policy. Staff confirmed that the necessary assessment to determine the resident's competence for self-administration had not been performed.
A resident with neurogenic bladder, severe morbid obesity, and diabetes was admitted with an indwelling urinary catheter, as documented in clinical records and physician orders. However, the admission MDS assessment failed to indicate the presence of the catheter, contrary to RAI Manual requirements. This inaccuracy was confirmed through record review and staff interview.
Three residents with respiratory conditions did not have their oxygen tubing, nebulizer machines, or nebulizer tubing changed or cleaned as required, with equipment found stained, dusty, or not changed for extended periods. Staff confirmed the equipment should be changed weekly, but no policy was available, and physician orders for weekly changes were not followed.
Prescription medications were found unsecured on top of an unlocked medication cart in a high-traffic area without staff supervision, and two vials of prescription aerosol medication were left in a resident's room who did not have a physician's order for them. An LPN confirmed these medications should have been secured, and facility policy required all medications to be stored in locked areas inaccessible to residents and visitors.
Two residents experienced incomplete and inaccurate medical record documentation, including missing entries for nebulizer treatment administration and urinary catheter output. Observations included a dirty nebulizer machine not properly stored and multiple omissions in required documentation, with the DON confirming that all documentation should have been completed.
Surveyors found that infection control practices were not followed for three residents: a nebulizer machine and mask were left dirty and improperly stored, a urinary catheter bag was placed on the floor, and soiled linens and a brief were left on the floor. Staff interviews confirmed these actions were not in line with facility policy.
A cockroach was observed outside a resident's room, and the resident confirmed seeing the pest near his door. Review of the facility's pest control policy showed a requirement to keep the environment free from pests, but the presence of the cockroach indicated a failure to meet this standard.
Surveyors found that the facility exceeded the acceptable medication error rate, with errors including a nurse failing to instruct a resident to rinse and spit after inhaler use and not priming insulin pens before administration to another resident, contrary to medication instructions and facility protocols.
A resident with diabetes and thyroid disorder was found with multiple pills left at the bedside without staff present, and there was no completed self-administration medication assessment in the clinical record. Facility policy requires medications to be securely stored, and staff confirmed the medications should not have been left in the room.
Surveyors found that a resident's Wixela inhaler and a Lantus Solostar insulin pen on a medication cart were not dated when opened, despite facility policy requiring opened dates for medications with shortened expiration periods. An RN confirmed these items should have been dated, and the DON provided the current policy supporting this requirement.
An LPN did not perform hand hygiene before putting on gloves or after removing them while administering insulin to a resident, and exited the room wearing used gloves. The facility's policies and competencies require hand hygiene at these steps and removal of gloves before leaving the room.
The facility failed to secure hazardous materials in the Soiled Utility Room, as observed on two occasions. The room's door was found unlocked with no staff present, and sharps containers were improperly stored, exposing used needles. Both the Maintenance Director and DON confirmed the door should have been locked, as per the facility's Bloodborne Pathogens Exposure Control Plan.
The facility failed to document drug dispositions for two residents, leading to a deficiency in pharmaceutical services. One resident with Alzheimer's and another with schizophrenia were transferred or discharged without proper documentation of medications sent with them. The facility's policy requires a Product Destruction form to be completed, which was not done.
A resident with respiratory failure, COPD, opioid dependence, and hepatitis C received a Fentanyl patch on the wrong day due to a QMA's error. The patch was administered a day early without notifying the nursing staff or physician, contrary to the physician's order and facility policy. The error was discovered when the resident reported it, highlighting a failure to follow medication administration protocols.
Care Plans Did Not Match Documented Code Status
Penalty
Summary
The facility failed to ensure resident care plans were revised to reflect the accurate code status for 2 of 24 residents reviewed for care plan accuracy. For Resident 4, the clinical record showed diagnoses including dementia and type 2 diabetes. An active physician’s order indicated a DNR code status, and an Indiana POST form signed by the resident’s representative and the physician also indicated DNR. However, the care plan dated 6/25/25 included an approach stating, "Honor resident wishes including discharge goal: LTC, code status: full code," which did not match the resident’s documented DNR status. A later care plan dated 7/1/25 stated that the resident/legal representative had formulated an advanced directive: DNR. For Resident 62, the clinical record showed diagnoses including chronic kidney disease and transient ischemic attack. An active physician’s order indicated DNR, and an Indiana POST form signed by the resident’s representative and the physician also indicated DNR. However, the care plan dated 12/2/25 included an approach stating, "Honor resident wishes including discharge goal: home, code status: Full code," which did not match the documented DNR status. A later care plan dated 12/3/25 stated that the resident/legal representative had formulated an advanced directive: DNR. During interview, the Administrator stated the care plans should have been revised to reflect only the current DNR code status preferences for both residents.
Unassessed Self-Administration and Unsupervised Medications Left in Resident Room
Penalty
Summary
The facility failed to ensure a resident was properly assessed and authorized to self-administer medications before leaving medications unsupervised in the resident's room. During observation, two pill cups were found on the resident's dresser. One cup, labeled with the resident's name, contained an unmarked small white pill. The second, unlabeled cup contained a large piece of candy, an unmarked small white pill, a yellow capsule, and a large white tablet. An LPN compared the pills in the cups to the resident's medications and identified them as melatonin 5 mg, gabapentin 300 mg, and gabapentin 600 mg, and stated the medications should not have been left in the room. Record review showed the resident had diagnoses including chronic pain and neuropathy and was cognitively intact per an annual MDS assessment. Physician orders included gabapentin 300 mg twice daily, gabapentin 600 mg at bedtime, and melatonin 5 mg at bedtime. However, the clinical record did not contain a self-medication administration assessment or a physician's order authorizing the resident to self-administer medications. The facility's policy on self-administration of medications required completion of a self-administration assessment and a physician's order specifying the resident's ability to self-administer, but these were absent in this case.
Failure to Maintain Clean and Sanitary Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, sanitary, and safe environment in three randomly observed resident rooms. In one room, a full, closed urinal containing dark yellow urine was observed sitting on the floor near a cluttered window area with personal belongings along the wall. The resident in that room reported the urinal had been on the floor for a couple of days. When interviewed, an LPN acknowledged that the urinal should have been emptied and not left on the floor. In a second room, the bathroom had a strong odor of urine and feces, with dried feces visible on the rim of the toilet bowl and on the toilet seat. A trash can without a bag was almost full of toilet paper with dried feces on it, and another trash can without a bag contained a urine-soiled brief. A CNA stated the trash cans should have had bags and been emptied, and that staff should have notified housekeeping to clean the toilet. In a third room, a white hospital blanket folded on the bathroom floor in front of the toilet was stained dark brown. The resident reported placing a folded blanket on the floor because the toilet leaked, and that the blanket was changed every week or two. A CNA confirmed the blanket had been changed about weekly and stated it should not have been left on the floor.
Failure to Maintain Effective Pest Control in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program when roach-like insects were observed in two resident rooms during surveyor observations. In one room, a dresser held a meal tray from the previous night’s dinner with dried peas, potatoes, and an open chocolate pudding cup, and a small roach-like insect was seen crawling out of the peas; the resident in that room stated he had not seen a roach in his room for about a week and confirmed the tray was from the prior evening. In another room, a roach-like insect was observed crawling up the bathroom wall underneath the sink. A pest control report dated several months earlier documented that cockroaches had been noted in resident rooms and hallways, and that access for pest control service was limited due to clutter and stored items, with most resident rooms having too much clutter to be properly serviced. The facility’s pest control policy stated that the facility would maintain an effective pest control program so that the facility is free of pests. These observations and records show that despite an existing pest control policy and prior pest control service noting cockroach activity and access limitations, pests continued to be present in resident rooms, and environmental conditions such as clutter and leftover food impeded effective pest management.
Staff Member Posted Unauthorized Photo of Cognitively Impaired Resident Online
Penalty
Summary
A staff member, specifically an Activity Assistant, took a photograph of a resident who was severely cognitively impaired and resided on the secured memory care unit. The resident had diagnoses including Alzheimer's disease, delusional disorder, and cognitive communication deficit. The photograph depicted the resident sitting in a wheelchair holding a baby doll, staring at the camera without a smile. The image was posted online by the Activity Assistant, accompanied by a caption containing inappropriate language and referencing the resident and the baby doll. The staff member posted the photograph on a social media website without obtaining authorization from the resident's family or the facility. This action was in direct violation of the facility's policy, which prohibits mental abuse and the unauthorized sharing of confidential information. The incident was discovered and reported by the facility, and documentation confirmed that the staff member had violated both HIPAA and the facility's confidentiality policies.
Unsanitary Kitchen Floors and Storage Areas
Penalty
Summary
During a kitchen inspection, surveyors observed a buildup of an unknown dark substance, dust, debris, a screwdriver, and several plastic lids under a freezer in the main kitchen area. Additionally, there was a buildup of dust and debris under the shelves in the dry storage room. The dietary supervisor acknowledged that these areas should have been cleaned. Review of the facility's policy on cleaning floors, tables, and chairs confirmed that kitchen floors are required to be kept clean and sanitary. These findings indicate that the facility failed to maintain a sanitary environment for food service as required by professional standards.
Failure to Implement Fall Prevention Care Plan Intervention
Penalty
Summary
The facility failed to implement person-centered care plan interventions for a resident identified as high risk for falls. Observation revealed that the resident's bed was not in the lowest position, contrary to the care plan intervention and a current physician's order, both of which specified that the bed should be kept in the lowest position. The resident, who had diagnoses including congestive heart failure, diabetes, and respiratory failure, was moderately cognitively impaired and had a documented history of two or more falls with injury. During the observation, a QMA confirmed that the bed should not have been left elevated. Review of facility policy indicated that a person-centered care plan should be developed and implemented for every resident.
Failure to Serve Palatable and Properly Heated Meals
Penalty
Summary
The facility failed to ensure that meals were served to residents at a palatable and proper temperature, as required by policy. Observations showed that a meal tray for one resident was left on a metal cart in the hallway for approximately 20 minutes before being delivered to the resident's room. When the resident attempted to eat, she was unable to cut the sausage, describing it as rubbery, and indicated that her food was cold. She also stated that she rarely received hot food because it often sat in the hallway before being served. Another resident was observed eating only about half of her meal and leaving the rest uneaten, with a balled-up napkin on the plate. She reported that her food was not hot and that she did not request reheating because it took too long. The facility's current policy requires that all hot and cold food be served at a palatable temperature at the time it is received by the resident. These findings were based on direct observation, resident interviews, and a review of facility policy.
Failure to Implement Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident with an indwelling urinary catheter, as required by both the resident's care plan and facility policy. During a transfer of the resident to bed using a mechanical lift, an LPN wore gloves but did not wear a gown, and a CNA wore neither gloves nor a gown. Personal protective equipment, including gowns and gloves, was available in the resident's room, but was not utilized as required during the high-contact care activity. The CNA later confirmed in an interview that staff should have been wearing a gown and gloves during the transfer. The resident involved had a diagnosis of obstructive uropathy and a documented indwelling urinary catheter, placing them at increased risk for colonization or infection with multi-drug resistant organisms. The care plan specifically identified the need for enhanced barrier precautions, including the use of gown and gloves during transfers. The facility's current policy, provided by the Director of Nursing, also required staff to wear gown and gloves for residents with indwelling urinary catheters during transfers, but this protocol was not followed during the observed event.
Failure to Maintain Sanitary Environment Due to Floor Buildup
Penalty
Summary
During an initial tour of the 100 Hall, surveyors observed a buildup of an unknown black substance along the floorboards and floorboard trim throughout the hallway. The substance was described as thick, black, tar-like, and mixed with hair and other debris. Further observation showed approximately six inches of this substance being scraped up, confirming its unsanitary nature. The DON acknowledged that the buildup should have been removed during routine housekeeping. The Housekeeping Supervisor stated that floors are cleaned daily and staff are expected to scrape off such buildup during cleaning. The facility was unable to provide a relevant policy regarding this issue by the time of survey exit.
Failure to Complete Self-Medication Assessment for Resident
Penalty
Summary
A deficiency occurred when a resident was observed with a pill cup containing a round brown tablet, identified as senna 8.6 mg, left on their bedside table. The resident, who had diagnoses including diabetes and metabolic encephalopathy and was assessed as having minimal cognitive impairment, did not have a completed self-medication administration assessment in their clinical record. Facility staff, including an LPN and the DON, confirmed that no such assessment had been performed. The facility's policy requires an interdisciplinary team assessment of a resident's competence before allowing self-administration of medications, but this process was not followed in this instance.
Inaccurate MDS Assessment for Resident with Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident admitted with an indwelling urinary catheter. The resident, who had diagnoses including neurogenic bladder, severe morbid obesity, and diabetes, was admitted with an indwelling urinary catheter as documented in the clinical record and physician's orders. However, the admission MDS assessment did not indicate the presence of the catheter, despite the Resident Assessment Instrument (RAI) Manual requiring documentation of an indwelling urinary catheter if used at any time in the seven days prior to the assessment date. This discrepancy was confirmed through record review and staff interview.
Failure to Maintain and Change Respiratory Equipment as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not ensuring that oxygen tubing, nebulizer machines, and nebulizer tubing were properly maintained and changed as required. Observations revealed that one resident's nebulizer machine was stained, dusty, and placed on the floor, with the face mask left uncovered on a heating unit and not changed since the date marked over a month prior. Another resident's oxygen concentrator was found with humidity water and nasal cannula tubing that had not been changed for nearly two months. A third resident was observed using a nebulizer mask with mist spraying into the air, with the oxygen concentrator on the floor and humidity water not changed for almost a month. In all cases, the equipment was not maintained according to the facility's expected weekly change schedule. Interviews with staff, including an LPN and the DON, confirmed that the respiratory equipment should have been changed weekly, but there was no policy available to support this practice. The clinical records for the residents indicated diagnoses such as chronic obstructive pulmonary disease, dementia, morbid obesity, encephalopathy, and neurogenic bladder, with physician orders specifying the frequency for changing respiratory equipment. Despite these orders, the facility did not ensure compliance, resulting in the cited deficiency.
Failure to Secure Prescription Medications and Improper Medication Storage
Penalty
Summary
Surveyors observed that prescription medications were not properly secured on two separate occasions. On one occasion, two prescription medications, H-Chlor12 wound cleanser and lactulose solution, were found sitting on top of an unlocked medication cart in a high-traffic resident area without staff supervision. An LPN confirmed that these medications should have been secured and the cart locked or supervised. On another occasion, two unopened vials of albuterol inhalation solution were found in a resident's room, next to a nebulizer mask, rather than being secured in the medication cart as required. The LPN acknowledged that these medications should have been secured. A review of the resident's clinical record revealed that the resident had diagnoses including chronic obstructive pulmonary disorder, dementia, and morbid obesity. The resident had a physician's order for ipratropium-albuterol inhalation solution, but not for the albuterol inhalation solution that was found in the room. Facility policy required all medications and treatment items to be stored in a locked cabinet, cart, or medication room inaccessible to residents and visitors. These observations and record reviews demonstrated a failure to follow the facility's medication storage policy.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate documentation for two residents. For one resident with chronic obstructive pulmonary disorder, dementia, and morbid obesity, a dirty nebulizer machine was observed on the floor, with the face mask not stored in a bag and dated over a month prior. Review of the Medication Administration Record (MAR) revealed multiple instances where required documentation for administration of ipratropium-albuterol nebulizer solution was incomplete or missing, including omissions of pulse, respirations, breath sounds, and minutes of therapy before and after administration across several dates. For another resident with neurogenic bladder, severe morbid obesity, and diabetes, the physician's order required recording urine output from a urinary catheter every shift. The Treatment Administration Record (TAR) showed missing documentation of urinary output for several shifts during the period the order was active. During an interview, the Director of Nursing confirmed that all documentation should have been completed, and there was no facility policy on documentation.
Infection Control Lapses in Equipment and Linen Handling
Penalty
Summary
Surveyors observed multiple failures in infection control practices involving three residents. For one resident with chronic obstructive pulmonary disorder, dementia, and morbid obesity, a dirty nebulizer machine was found on the floor next to a heat unit, with the face mask not stored in a bag but left exposed on the heat unit. The nebulizer mask was dated over a month prior to the observation. An LPN confirmed that the nebulizer should not have been on the floor and the mask should have been bagged. The resident's clinical record indicated a physician's order for frequent nebulizer treatments. Another resident with encephalopathy and neurogenic bladder was found to have a urinary catheter bag sitting directly on the floor, containing approximately 400 ml of urine. Both a QMA and an RN acknowledged that catheter bags should not be left on the floor. In a separate incident, a soiled brief, gown, and linen were observed lying on the floor in a room of a resident with lung cancer, dementia, and dysphagia, who was always incontinent of bladder. A CNA confirmed that these soiled items should not have been left on the floor. Facility policy reviewed by the DON specified that urinary drainage bags should not touch the floor, contaminated linen should be bagged, and equipment should be stored to prevent contamination.
Failure to Maintain Pest-Free Environment
Penalty
Summary
A brown cockroach was observed crawling on the floor outside a resident's room during a random observation. At that time, the resident reported having seen a roach near his door. The facility's current pest control policy, dated September 2023, was reviewed and indicated that the facility is required to maintain an effective pest control program to ensure the environment is free from pests. Despite this policy, the presence of a cockroach was confirmed through direct observation and resident interview.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, with surveyors identifying a 16 percent error rate during their review. In one instance, a registered nurse administered Wixela and Incruse Ellipta inhalers to a resident but did not instruct the resident to rinse and spit out water after administration, as required by both the medication instructions and the facility's competency guidelines. The nurse indicated that rinsing was not necessary, despite clear instructions to the contrary. In another instance, the same nurse administered Lantus Solostar and Humalog KwikPen insulin to a different resident without priming either insulin pen prior to injection. The nurse stated that priming was not needed, although both the manufacturers' instructions and the facility's competency guidelines specify that priming is required to ensure accurate dosing. These actions were observed and confirmed through interviews and record reviews, leading to the cited deficiency.
Failure to Complete Self-Administration Medication Assessment and Improper Medication Storage
Penalty
Summary
A resident with diagnoses including diabetes and thyroid disorder was observed with three pills—a small purple pill, a small white pill, and a yellow capsule—left in a plastic medication cup on the bedside table without staff present. Staff confirmed that these medications should not have been left in the resident's room. Review of the resident's clinical record revealed there was no completed self-administration medication assessment. Facility policy requires medications to be stored in a locked cabinet, cart, or medication room inaccessible to residents and visitors. The Director of Nursing confirmed that the required assessment was not present and that medications should not have been left at the bedside.
Failure to Date Opened Medications on Medication Cart
Penalty
Summary
Surveyors observed that medications on the 200 Hall medication cart were not dated when opened, as required by facility policy and professional standards. Specifically, a Wixela inhaler prescribed for a resident with chronic obstructive pulmonary disease was found in a clear bag in the medication cart with no opened date indicated on the package or inhaler, despite the label showing it was filled with 60 doses and 47 doses remained. Additionally, a Lantus Solostar insulin pen with a broken seal was present in the same cart drawer without an opened date on the label or pen. During interviews, a registered nurse confirmed that both the inhaler and insulin pen should have been dated upon opening. The facility's current policy, provided by the Director of Nursing, requires that the date opened be documented on medication containers when the expiration date is shortened after opening.
Failure to Follow Infection Control Protocol During Insulin Administration
Penalty
Summary
A deficiency was identified when an LPN failed to follow proper infection control practices during the administration of insulin to a resident. The LPN entered the resident's room with insulin pens, donned clean gloves, and administered the insulin without performing hand hygiene beforehand. After the procedure, the LPN exited the resident's room while still wearing the used gloves and only removed them after leaving the room, again without performing hand hygiene. The LPN acknowledged the lapse in hand hygiene and glove removal protocol. Review of the facility's current skills competency and infection prevention policy confirmed that hand hygiene should be performed before donning gloves and after removing them, and gloves should be removed prior to exiting the resident's room.
Failure to Secure Hazardous Materials in Soiled Utility Room
Penalty
Summary
The facility failed to ensure that potentially hazardous materials were kept secure, as observed during two separate instances. On January 27, 2025, at 9:05 a.m., the door to the Soiled Utility Room on the west hall across from the laundry room was found unlocked with no staff present. Inside the room, four full sharps containers were observed, with one container unsecured and lying on its side, exposing used needles. The Maintenance Director confirmed that the door was supposed to be locked. Later, at 10:00 a.m., the door was again observed to be unlocked with no staff in the area. The Director of Nursing (DON) also confirmed that the door should have been locked. The facility's Bloodborne Pathogens Exposure Control Plan, revised in December 2023, was provided by the DON, which included procedures for properly sealing sharps containers.
Failure to Document Drug Dispositions for Residents
Penalty
Summary
The facility failed to document the drug dispositions for two residents, leading to a deficiency in pharmaceutical services. Resident 295, diagnosed with Alzheimer's disease and transient cerebral ischemic attack, was transferred to another facility with medications including Eliquis, Norvasc, and Vitamin D3. However, the clinical record lacked documentation of the name, type, or amount of medications sent with the resident. The Regional Director of Nursing confirmed the absence of this documentation during an interview. Similarly, Resident 91, who had diagnoses of schizophrenia and anxiety disorder, was discharged home with family. The resident's medications included Clozapine, Miralax, Terbinafine HCl, and Sertraline. Like Resident 295, the clinical record for Resident 91 also lacked documentation of the medications sent home. The facility's Drug Disposition Policy requires a Product Destruction form to be printed, signed, and placed in the resident's clinical record, which was not adhered to in these cases.
Improper Administration of Fentanyl Patch
Penalty
Summary
The facility failed to ensure proper administration of pain medication for Resident B, who was diagnosed with respiratory failure, COPD, opioid dependence, and hepatitis C. A Qualified Medication Aide (QMA 2) administered a Fentanyl transdermal patch on the wrong day, contrary to the physician's order. The order specified that the patch should be applied every three days, with the old patch removed and disposed of properly. However, QMA 2 replaced the patch a day early, on the evening of 9/28/24, without notifying licensed nursing staff, a supervisor, or the physician. This error was discovered when Resident B informed the staff the following day. The Director of Nursing (DON) confirmed that the error occurred and that the Fentanyl patch was not scheduled to be changed until the next day. The facility's policy on medication administration, which requires verification of the correct time for medication administration, was not followed. The incident was related to a complaint, and the facility's policy dated 12/1/07 was reviewed, indicating the need for adherence to medication administration protocols.
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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 Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany Village | 1.6 mi | ★★★★★ | 18 | 0 |
| Waters Of Indianapolis, The | 1.9 mi | ★★★★★ | 2 | 0 |
| Majestic Care Of Southport | 2 mi | ★★★★★ | 5 | 0 |
| Altenheim Health & Living Community | 2.5 mi | ★★★★★ | 2 | 0 |
| Hawthorne Healthcare Center | 2.7 mi | ★★★★★ | 10 | 0 |
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