Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hawthorne Healthcare Center during CMS and state inspections, most recent first.
Unsecured hazardous materials and electrical room: A conference room near the entrance was found unlocked with multiple bottles of Rx Destroyer drug disposal formula left out in the open, including one on a table and others on the floor. An Electrical Room/Mechanical Room on the 600-hallway was also observed unlocked on multiple occasions while residents were nearby; inside were exposed cables, power panels, bare circular saw blades, dangerous voltage labeling, and an unlocked fuse panel.
Enteral feeding order not followed and tube feeding equipment left undated. A resident with a G-tube was observed with a kangaroo pump and Osmolite formula hanging at the bedside, but the bottle and tubing were undated. The chart contained an oral Osmolite order, while an RN later stated a weekend supervisor obtained a phone order for Osmolite 1.5 via G-tube after the resident refused the oral supplement, but the order was not documented in the EHR.
A resident with severe cognitive impairment and a history of wandering exited the secured memory care unit without staff knowledge when the only CNA assigned to the unit left it unattended. The resident was found by police approximately 1.5 miles from the facility and returned safely. Documentation showed the resident was at risk for elopement and required supervision, but no staff were present on the unit at the time of the incident.
The facility failed to maintain sanitary conditions in food service as Dietary staff was observed with uncovered facial hair while working in the kitchen. Despite the facility's policy requiring hair and facial hair to be covered, staff was seen plating meals and taking temperatures without proper hair restraints, violating sanitation requirements.
A facility failed to create a comprehensive care plan for a resident with an indwelling urinary catheter, despite the resident being cognitively intact and having a diagnosis of neuromuscular dysfunction of the bladder. The absence of a care plan was confirmed through observations and interviews, and the facility's policy on personalized care was not followed.
The facility failed to properly dispose of garbage and refuse, as observed during a tour and follow-up inspection. A large cardboard box with debris was found outside the kitchen's rear door, and the sliding side panel door of a dumpster was left open. The Dietary Manager confirmed that dumpster lids and doors should be closed when not in use, and all debris should be placed in dumpsters. The facility's policy and sanitation requirements mandate proper disposal and covering of waste receptacles.
A resident with epilepsy, alcohol dependence, and vascular dementia was transferred to another facility without notifying their guardian, as required by the facility's policy. The clinical record lacked documentation of the notification, and staff interviews confirmed the oversight.
A facility failed to provide a written Notice of Transfer/Discharge to a resident's representative before discharge. The resident, with diagnoses including epilepsy and vascular dementia, was discharged to another facility without the required documentation. A corporate nurse confirmed the lack of additional discharge documentation, and the facility's policy was reviewed, highlighting the need to record reasons for transfer or discharge.
The facility failed to document medication administration for two residents, despite the Corporate Nurse's indication that the medications were given. Medications for conditions such as central nervous system disorders, pain relief, acid reflux, diabetes, and depression were not recorded as administered according to physician's orders. The facility's policy requires medications to be charted when given, which was not followed.
The facility restricted access to the courtyard for several cognitively intact residents, allowing them outside only during supervised smoking times. This policy was implemented after a resident altercation, despite residents expressing the importance of outdoor access for their well-being. Interviews and records showed that the restriction affected their psychosocial health and self-determination.
A resident with severe cognitive impairment was observed with a scrape, swelling, and bruising on the nose and left eye, but the facility failed to report this injury of unknown origin to the state health department. Despite multiple staff members noticing the injury and a physician's order for an x-ray, the injury was not documented in a timely manner, and the facility's policy requiring reporting of such injuries was not followed.
A resident with autism, intellectual disability, and epilepsy was found with a scrape, swelling, and bruising on his nose and left eye. Despite a physician's order for an x-ray and observations by staff, the facility failed to investigate the injury's origin. The DON observed the resident bump into a wall but did not document it promptly. The facility's policy mandates investigation of unknown origin injuries, but the source was not identified by survey exit.
The facility failed to provide the required written bed hold policy to two residents during their transfers to the hospital. One resident, with end-stage renal disease, called 911 due to nausea and pain, while another resident with thumb wounds requested hospital transfer due to pain and inflammation. In both cases, the facility did not document that the bed hold policy was provided, contrary to their policy.
The facility failed to secure and properly label medications, including Ativan and TPN. Ativan, a controlled substance, was not double locked in the medication room, and TPN was not labeled with the nurse's initials or date in a resident's room. The facility lacked a policy for medication labeling.
A facility failed to notify a physician when a large knife was found in a resident's drawer, who had a history of suicidal ideations and attempts. The CNA reported the knife to the LPN and DON, who instructed the CNA to place it in the medication room, but the physician was not informed. The resident had a history of major depressive disorder, suicidal ideation, and multiple suicide attempts, yet the facility's records lacked documentation of physician notification, contrary to facility policy.
A resident with a history of IV drug use alleged that a nurse supplied her with heroin, leading to an emergency requiring CPR and Narcan. The resident, who was moderately cognitively impaired, later identified the LPN involved to the Administrator. Despite the facility's policy requiring such incidents to be reported to state authorities, the Administrator did not report the allegation, believing it was unnecessary as the investigation was ongoing.
A facility failed to implement person-centered care plans for a resident with suicidal ideations and a history of trauma and suicide attempts. A CNA found a large knife in the resident's drawer, which was placed in the medication room. The resident's clinical record showed diagnoses of major depressive disorder, panic disorder, and PTSD, but lacked care plans for suicidal ideations and attempts. Despite the resident's history of suicide attempts and psychiatric hospitalizations, the facility did not adhere to its policy requiring care plans with specific interventions.
A resident required emergency medical intervention after an opioid overdose, allegedly receiving heroin from an LPN at the facility. The incident was not reported to the state health department or police as required by facility policy, leading to a deficiency finding.
The facility failed to provide necessary behavioral health services for two residents with a history of aggression and substance use disorder. Despite previous incidents, neither resident had documented interventions to address or prevent aggressive behaviors. Additionally, a resident with alcohol dependence was found intoxicated multiple times without a documented plan for prevention and treatment. The facility's behavior management policy requires updating care plans with changes or new behaviors, but this was not adhered to, leading to the deficiency.
A resident with C. diff received only 8 of 39 doses of prescribed vancomycin due to a failure in communication and action. The pharmacy delivered an oral solution instead of capsules, but the facility did not notify the physician or update the order. The medication was not administered as prescribed, and unopened bottles were found in the medication room.
The facility failed to maintain accurate and complete documentation on the MAR and TAR for five residents, leading to missing entries for various medications and treatments. Residents reported issues such as uncertainty about medication administration and unavailability of medications. The DON acknowledged the documentation should have been completed accurately.
A facility failed to implement transmission-based precautions for a resident with C. diff. The resident's clinical record lacked a physician's order for precautions, and staff were unaware of the diagnosis, leading to inadequate infection control measures. The DON was not informed of the resident's condition upon admission, highlighting a communication breakdown.
A facility failed to notify hospice when a resident, on hospice care for Fournier's gangrene, received new orders for intravenous antibiotics. The resident was supposed to start oral doxycycline, but instead, a midline was placed, and intravenous levofloxacin was administered without hospice notification. The hospice VP confirmed the delay in notification, and the order for doxycycline was not transcribed to the electronic medical record. The DON acknowledged the oversight, which led to a deficiency in care coordination.
Unsecured hazardous materials and electrical room
Penalty
Summary
The facility failed to ensure potentially hazardous materials were kept secure behind locked doors to prevent resident access. On 12/1/25, a conference room near the front entrance was observed ajar and unlocked, and inside were nine bottles of Rx Destroyer drug disposal all-purpose formula, including one mostly full bottle on a table and eight additional full bottles on the floor near a waste receptacle. The bottle labels indicated to keep out of reach and to always store in a secure location, and no staff were noted in the immediate area. The facility also failed to keep an Electrical Room/Mechanical Room locked. On 12/2/25 and again on 12/3/25, the door to the room on the 600-hallway was observed unlocked while no staff had a direct line of sight to the area and multiple residents were moving through or near it. When the room was observed inside on 12/3/25, it contained power supply panels, exposed electric, internet, and other cables and cords, bare circular saw blades suspended above a doorway, additional power control panels, a large panel labeled with dangerous voltage warnings, and an unlocked panel of electrical fuses. The Director of Plant Operations, Maintenance Tech 1, the Administrator, and the VPORM indicated the rooms containing these hazards should be kept locked, and the facility’s hazardous materials policy stated hazardous materials should be kept out of reach of those who might inadvertently become exposed or injured.
Enteral Feeding Order Not Followed and Tube Feeding Equipment Left Undated
Penalty
Summary
The facility failed to ensure that physician orders were followed for a resident receiving enteral feedings and failed to ensure feeding equipment was dated. Resident 6 was observed in bed with a kangaroo pump and a 1000 ml bottle of Osmolite 1.5 cal hanging from the pole and connected to the pump, but not connected to the resident at that time. The bottle contained a brown liquid and both the bottle and tubing were undated. Resident 6 stated he did receive Osmolite 1.5 by G-tube. Record review showed Resident 6 had diagnoses including intestinal bypass and anastomosis status and noninfective gastroenteritis and colitis. The physician's order in the record, initiated on 9/4/25, directed Osmolite 1.2 cal, 355 ml every 6 hours by mouth as needed for supplement. Resident 6 stated he did not get Osmolite by mouth because he had a feeding tube in place and said he had received Osmolite 1.5 via the feeding tube a few days earlier. The Divisional Director for Clinical Operations stated the weekend supervisor had obtained an order to administer Osmolite 1.5 cal via G-tube after Resident 6 refused the oral Osmolite 1.2 cal, but the order was not documented or entered into the electronic health record. Facility policy required verification of the practitioner's order, including route and formula, and required feeding syringes, tubing, or bottles to be changed daily and labeled and dated.
Resident Elopement Due to Lack of Supervision on Secured Memory Care Unit
Penalty
Summary
A cognitively impaired resident with diagnoses including Alzheimer's disease and dementia, and a history of wandering, exit seeking, and elopement, was able to exit the secured memory care unit of the facility without staff knowledge. The resident was under guardianship and had been assessed as severely cognitively impaired, with care plans in place identifying the risk for elopement and interventions such as diversionary activities and redirection. Despite these interventions, the resident had demonstrated exit-seeking behaviors prior to the incident, including multiple attempts to leave and verbalizing a desire to go home. On the night of the incident, the only CNA assigned to the secured memory care unit left the unit unattended due to a personal emergency, leaving no staff present. During this time, the resident exited the facility through an emergency exit door, which triggered an alarm. Staff became aware of the resident's absence only after the alarm sounded and the resident was discovered missing. The resident was subsequently found by police approximately 1.5 miles from the facility, near a busy intersection, and was returned to the facility. Facility records, including staff witness statements and clinical documentation, confirmed that the resident had a documented history of wandering and exit-seeking, and that the care plan required supervision and specific interventions to prevent elopement. The facility's policy defined elopement as a resident leaving the premises or a safe area without authorization or necessary supervision, placing the resident at risk for harm. The lack of staff presence on the secured unit directly led to the resident's unsupervised exit from the facility.
Removal Plan
- audits of elopement evaluations and care plans
- inservicing staff on elopement procedures
- ongoing monitoring
Failure to Maintain Sanitary Conditions in Food Service
Penalty
Summary
The facility failed to ensure food was served in a sanitary manner during three of four kitchen observations. Dietary staff, identified as Dietary [NAME] 2, was observed on multiple occasions with uncovered facial hair while working in the kitchen. Specifically, on November 6, 2024, from 11:20 a.m. to 11:23 a.m., Dietary [NAME] 2 was seen near the steam table area with facial hair approximately one-half inch in length above and below the lips, which was not covered. This observation was repeated during a follow-up from 11:35 a.m. to 11:40 a.m., and again from 12:12 p.m. to 12:20 p.m., while Dietary [NAME] 2 was taking meal temperatures and plating meals. During an interview, the Regional Dietary Consultant confirmed that staff hair, including facial hair, should be covered while in the kitchen. The facility's Staff Attire policy, dated September 2017, was reviewed and indicated that all staff members must have their hair confined in a hair net and facial hair properly restrained. Additionally, the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24 mandates that food employees wear hair restraints, including beard restraints, to prevent hair from contacting exposed food.
Failure to Develop Care Plan for Catheter Care
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who had an indwelling urinary catheter. The resident, who was cognitively intact and diagnosed with neuromuscular dysfunction of the bladder, had the catheter since October 1, 2024. Despite the presence of physician's orders for the catheter, the resident's clinical record did not include a care plan addressing the catheter care. Observations and interviews conducted over several days confirmed the absence of a care plan. The Corporate Clinical Nurse Consultant acknowledged that a care plan should have been developed for the resident's catheter care. The facility's Plan of Care Overview policy, which emphasizes resident-focused and personalized care, was not adhered to in this instance.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain proper disposal of garbage and refuse, as observed during a facility tour and follow-up inspection. During the initial tour with the Dietary Manager, a large cardboard box containing unidentifiable debris was found on the ground outside the kitchen's rear door, along with used cups, rags, and other debris. Additionally, the dumpster area, located approximately 100 yards from the kitchen's rear door, was observed to have two large dumpster containers. The east dumpster container had two sliding side panel doors, one of which was not closed. No staff were present in the area during these observations. A follow-up observation confirmed that the sliding side panel door on the east dumpster container remained open, with no staff visible in the area. The Dietary Manager confirmed that the dumpster container lids and sliding side panel doors should be kept closed when not in use, and all debris should be placed into the dumpster containers. The facility's Environment policy, dated September 2017, requires all trash to be properly disposed of in external receptacles, and the surrounding area to be free of debris. Additionally, the Retail Food Establishment Sanitation Requirements mandate that receptacles and waste handling units for refuse, recyclables, and returnables be kept covered with tight-fitting lids or doors if kept outside.
Failure to Notify Guardian Before Resident Transfer
Penalty
Summary
The facility failed to notify a resident's guardian prior to a transfer, which was identified during a review of Resident D's clinical record. Resident D, who had diagnoses including epilepsy, alcohol dependence, and vascular dementia, was appointed a guardian on 2/22/23. A progress note from 7/18/24 indicated that Resident D was discharged to another facility, but the clinical record lacked documentation that the guardian was notified before the discharge. During interviews, Corporate Nurse 1 confirmed there was no additional documentation regarding the discharge, and LPN 1 acknowledged that the guardian should have been notified prior to the transfer. The facility's policy on Admission, Discharge, and Transfer requires notifying the resident and their representative of the transfer or discharge in writing and recording the reasons in the medical record, which was not adhered to in this case.
Failure to Provide Written Notice of Transfer/Discharge
Penalty
Summary
The facility failed to provide a written Notice of Transfer/Discharge to the representative of a resident, identified as Resident D, prior to their discharge. Resident D had diagnoses including epilepsy, alcohol dependence, and vascular dementia, and had a guardian appointed on a previous date. The clinical record review revealed that Resident D was discharged to another facility, with all belongings sent along, but lacked documentation of the required written notice to the resident's representative. During an interview, a corporate nurse confirmed the absence of additional documentation regarding the discharge. The facility's policy on admission, discharge, and transfer was reviewed, which indicated the need to record reasons for transfer or discharge in the medical record.
Incomplete and Inaccurate Medication Documentation
Penalty
Summary
The facility failed to ensure that the medical records for two residents were complete and accurate, as medications were not documented when administered. For Resident B, the clinical record review revealed that medications including Carbidopa-Levodopa, Hydrocodone/Acetaminophen, and Omeprazole were not documented as administered according to the physician's orders on specific dates and times in August 2024. Despite the Corporate Nurse's indication that the medications were administered, the staff did not document the administration as required. Similarly, for Resident C, the clinical record review showed that several medications, including Furosemide, Amlodipine, Doxepin, Clonazepam, Insulin glargine, Trulicity, Insulin lispro, and Oxycodone/Acetaminophen, were not documented as administered according to the physician's orders over several days in August 2024. The Corporate Nurse confirmed that the medications were administered, but the staff failed to document the administration. The facility's policy on medication administration requires that medications be charted when given, which was not adhered to in these cases.
Facility Restricts Resident Access to Courtyard
Penalty
Summary
The facility failed to uphold resident rights by restricting access to the courtyard for five residents, all of whom were cognitively intact and expressed a desire to go outside for fresh air. This restriction was implemented following a resident altercation in the gazebo, leading the Executive Director to mandate supervision for any resident wishing to go outside, even during non-smoking times. Residents expressed dissatisfaction with this policy, as it limited their ability to enjoy the outdoors, which they felt was important for their well-being. Interviews with the residents revealed that they were informed by facility staff that they could only access the courtyard during designated smoking times or with supervision. The residents' records, including Minimum Data Set (MDS) assessments and care plans, indicated that going outside was important for their psychosocial well-being and that they were at risk for social isolation. Despite these documented needs, the facility maintained its restrictive policy, impacting the residents' quality of life and their right to self-determination.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to notify the state health department of an injury of unknown origin for Resident M, who was severely cognitively impaired with diagnoses including autistic disorder, intellectual disability, and epilepsy. Staff observed a scrape with swelling and bruising to Resident M's nose and left eye but did not know how the injury occurred. A physician's order for an x-ray was made after the Director of Nursing (DON) observed Resident M bump into a wall, but the injury may have been present before this incident. The x-ray showed no fracture or acute traumatic osseous abnormality. The injury was not documented in a timely manner, as the progress note was entered into the electronic medical record seven days after the x-ray was ordered. Interviews with staff revealed that the injury was noticed by multiple staff members, including the Activity Director and CNA 10, who reported the injury to RN 9 but felt it was not taken seriously. The facility's policy required that all allegations involving injuries of unknown origin be reported to the state, but this was not done. The Administrator was aware of the injury during a clinical meeting but needed to follow up with the DON to determine the cause. The facility's failure to report the injury of unknown origin to the state health department constituted a deficiency.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for Resident M, who was observed with a scrape on his nose, swelling, and bruising on his nose and left eye. Resident M's clinical record indicated diagnoses of autistic disorder, intellectual disability, and epilepsy, and a quarterly MDS assessment noted that Resident M was rarely or never understood. On a specific date, a physician's order was made for an x-ray of Resident M's nose due to swelling and a suspected mass, but the x-ray results showed no fracture or acute traumatic abnormality. However, the progress note documenting the Director of Nursing (DON) observing Resident M bump into a wall was entered into the medical record seven days after the x-ray was ordered. Interviews revealed that the Administrator was informed of the injury during a clinical meeting, but the source of the injury was not identified. The DON indicated she saw Resident M bump into a wall but may not have been aware of the injury prior to this incident. A CNA reported the injury to an RN, but felt it was not taken seriously. An observation noted a small scratch and discoloration on Resident M's nose. The facility's policy required all injuries of unknown origin to be investigated, but by the survey exit, the facility had not identified the source of Resident M's injuries.
Failure to Provide Bed Hold Policy During Resident Transfers
Penalty
Summary
The facility failed to provide the required written bed hold policy to two residents, Resident D and Resident E, during their transfers to the hospital. Resident D, who was moderately cognitively impaired and diagnosed with end-stage renal disease, among other conditions, called 911 due to nausea, vomiting, and pain at his port site. The clinical record did not document that the bed hold policy was provided to him at the time of transfer or afterward. The Director of Nursing acknowledged that the staff should have provided the policy before Resident D left the facility and documented the action in a progress note. Similarly, Resident E, who had wounds on both thumbs and was his own responsible party, requested to be sent to the hospital due to hand pain, inflammation, and redness. The facility's records also lacked documentation that the bed hold policy was given to Resident E at the time of transfer or afterward. The facility's Administrator provided a copy of the current transfer and discharge policy, which indicated that the bed hold policy should be presented to the resident prior to transfer, but this was not followed in these cases.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper labeling of medications in the medication room and during random observations. During an observation, an unlocked medication refrigerator was found in the South Medication Room containing a clear plastic bag with Ativan, a controlled substance, which was not double locked as required. The Ativan was found in a pink bin with other medications instead of being secured in a lock box inside the refrigerator, as per the facility's policy dated September 2018. Additionally, a clear plastic bag containing TPN was observed hanging in a resident's room without being labeled with the nurse's initials or the date it was hung. The Director of Nursing acknowledged that the TPN should have been labeled and removed when the resident was transferred to the hospital four days prior. The facility was unable to provide a policy regarding the labeling of medications.
Failure to Notify Physician of Dangerous Item Found in Resident's Room
Penalty
Summary
The facility failed to notify the physician when a large knife was found in the drawer of a resident with a history of suicidal ideations and attempts. On July 2, 2024, a CNA discovered the knife while assisting the resident with counting money. The CNA reported the finding to the LPN and the DON, who instructed the CNA to place the knife in the medication room, promising to address the issue. However, the physician was not informed of this significant incident, which was a breach of the facility's policy requiring physician notification for new or unusual behaviors. The resident involved had a documented history of major depressive disorder with psychotic symptoms, panic disorder, assaultive behavior, suicidal ideation, and PTSD. The resident's clinical records revealed multiple past suicide attempts and psychiatric hospitalizations, including a recent overdose attempt. Despite this history, the facility's records lacked documentation of physician notification regarding the knife discovery, which was acknowledged as necessary by the DON during an interview.
Failure to Report Allegation of Abuse Involving Drug Supply
Penalty
Summary
The facility failed to report an allegation of abuse to the state health department concerning a resident with a history of intravenous drug use. The resident alleged that a nurse supplied her with heroin, which led to an incident requiring emergency medical intervention, including CPR and administration of Narcan. The resident initially withheld the source of the drugs but later identified an LPN as the supplier to the Administrator and Director of Nursing. Despite this serious allegation, the Administrator did not report the incident to the state health department, believing it was unnecessary as the investigation was still ongoing. The resident involved was moderately cognitively impaired, as indicated by an Admission MDS assessment. The facility's policy on Occurrence Incident Reporting classified such incidents as level 2, which are considered more serious and should be reported to state authorities. However, the Administrator did not adhere to this policy, resulting in a failure to report the allegation of abuse. This deficiency was identified during a complaint investigation related to the incident.
Failure to Implement Person-Centered Care Plans for Resident with Suicidal Ideations
Penalty
Summary
The facility failed to implement care plans with person-centered interventions for a resident diagnosed with suicidal ideations and a history of trauma and suicide attempts. During an interview, a CNA reported finding a large butcher knife in the resident's drawer, which was then placed in the medication room by the CNA as instructed by the DON. The resident's clinical record indicated diagnoses including major depressive disorder with psychotic symptoms, panic disorder, assaultive behavior, suicidal ideation, and post-traumatic stress disorder. Despite these significant mental health concerns, the clinical record lacked care plans addressing suicidal ideations and suicide attempts. The resident had a history of multiple suicide attempts and psychiatric hospitalizations, including a recent suicide attempt by overdose. The facility's progress notes indicated the resident expressed dissatisfaction with her medication regimen and had a history of impulsive behavior and insomnia. Despite these documented concerns, the facility did not have a care plan with specific interventions for the resident's suicidal ideations and attempts, as confirmed by the DON during an interview. The facility's policy on behavior management required care plans to be completed and updated with specific interventions, which was not adhered to in this case.
Failure to Report Alleged Abuse and Drug Incident
Penalty
Summary
The facility administration failed to maintain the mental and physical wellbeing of a resident, identified as Resident C, due to an unreported allegation of abuse involving a nurse. Resident C was sent to the emergency department after requiring CPR and Narcan, indicating an opioid overdose. The resident admitted to snorting heroin, which she claimed to have obtained from someone within the facility. Although Resident C initially withheld the source of the drugs, she later disclosed to the Administrator and the Director of Nursing (DON) that the drugs were provided by LPN 1. Despite this serious allegation, the incident was not reported to the state health department or the police in a timely manner. The Administrator confirmed that Resident C required emergency medical intervention in early July and suspected illegal drug use. Upon learning from Resident C that LPN 1 was the source of the drugs, the LPN was suspended, and an investigation was initiated. However, the police report provided by the Administrator was related to property disposal rather than the drug-related incident. The facility's policy on incident reporting categorizes such events as level 2 incidents, which should be reported to state authorities, but this protocol was not followed. This deficiency was identified during the investigation of Complaint IN00438670.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to maintain the highest practicable well-being for two residents with a history of aggressive behavior and substance use disorder. Resident B and Resident C, both with moderate cognitive impairments, were involved in a physical altercation in the courtyard. Despite previous incidents of aggression, neither resident had interventions documented in their clinical records to address or prevent such behaviors. Interviews with staff revealed that Resident B had previously been involved in a verbal disagreement with another resident, and Resident C had been verbally aggressive in a common area, yet no specific interventions were in place. Additionally, Resident B, who has a diagnosis of alcohol dependence and alcohol-induced persistent dementia, was found intoxicated on multiple occasions within the facility. The clinical record indicated incidents where Resident B was intoxicated, including hiding alcohol in the toilet tank and drinking mouthwash to the point of intoxication. Despite these occurrences, there was no documented plan for the prevention and treatment of Resident B's substance use disorder. The Director of Nursing acknowledged that a care plan should have been in place for Resident B's alcohol-related behaviors. The facility's policy on behavior management requires updating care plans with changes or new behaviors and including resident-specific interventions. However, the lack of documented interventions for both residents' aggressive behaviors and Resident B's substance use disorder indicates a failure to adhere to this policy, contributing to the deficiency in providing adequate behavioral health services.
Significant Medication Error Due to Miscommunication and Inaction
Penalty
Summary
The facility failed to prevent significant medication errors for a resident diagnosed with Clostridium difficile (C. diff), who only received 8 out of 39 prescribed doses of vancomycin. The resident was cognitively intact and had been discharged from the hospital with a prescription for vancomycin capsules to be taken four times daily for 12 days. However, the facility's Medication Administration Record showed multiple instances where the medication was either not documented, marked as awaiting pharmacy, or noted as not available. Despite the pharmacy delivering vancomycin oral solution instead of capsules, the medication was not administered as prescribed. The Director of Nursing and the Assistant Director of Nursing, who also served as the Infection Preventionist, acknowledged that the pharmacy delivered the oral solution because they did not carry the capsules. They admitted that the physician should have been notified about the change in medication form, and the order should have been clarified and updated in the medical record. The unopened bottles of vancomycin solution found in the medication room further indicated a lack of communication and follow-through in administering the medication as ordered. This deficiency was related to a complaint investigation.
Incomplete Documentation of Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure accurate and complete documentation on the medication administration record (MAR) and the treatment administration record (TAR) for five residents. Resident B expressed uncertainty about receiving all prescribed medications, and a review of the MAR revealed multiple instances of missing documentation for various medications, including atorvastatin, cholecalciferol, ferrous sulfate, insulin glargine, and others. Additionally, the TAR lacked documentation for wound care treatments on several dates. Resident D reported not receiving baclofen for muscle spasms due to the facility running out of the medication. The MAR for Resident D also showed missing entries for several medications, such as duloxetine, insulin glargine, Jardiance, and others. The TAR was incomplete for treatments like floating heels for pressure prevention. Similarly, Resident E mentioned instances where medications were unavailable, and the MAR showed missing documentation for medications like atorvastatin, ferrous sulfate, and Lantus solostar pen-injector. The TAR also lacked entries for wound care and the use of prevalon boots. For Resident F, the MAR for April 2024 was missing documentation for medications like levothyroxine, metoprolol, and pantoprazole. The TAR was incomplete for wound care treatments. Resident G's MAR also showed missing entries for medications such as Basaglar Kwikpen and fluticasone suspension, and the TAR lacked documentation for wound care treatments. The Director of Nursing acknowledged that the MARs and TARs should have been completed accurately, and the facility's policy indicated that medication documentation should follow accepted nursing standards.
Failure to Implement Transmission-Based Precautions for C. diff
Penalty
Summary
The facility failed to implement transmission-based precautions for a resident diagnosed with C. difficile, a highly contagious infection. Resident B, who was admitted with a diagnosis of C. diff, did not have a physician's order for transmission-based precautions in their clinical record. Despite being in contact precautions at the hospital, this information was not communicated to the facility staff. The resident's clinical record also lacked a specific order for the antibiotic Vancomycin to treat C. diff, which was part of the discharge instructions from the hospital. Interviews with facility staff revealed a lack of awareness regarding Resident B's C. diff diagnosis and the necessary precautions. A CNA who provided incontinence care to Resident B was not informed about the need for personal protective equipment and did not use any during care. Similarly, the housekeeping department was not notified of the need for transmission-based precautions. The Director of Nursing was unaware of the resident's C. diff status upon admission, indicating a breakdown in communication and adherence to the facility's infection prevention policy.
Failure to Notify Hospice of New Antibiotic Orders
Penalty
Summary
The facility failed to notify hospice when a resident received new physician orders for intravenous antibiotics. Resident C, who was on hospice services due to Fournier's gangrene, was supposed to start an oral antibiotic, doxycycline, on 5/24/24. However, a few days later, a family member was informed by a nurse that Resident C had a midline placed and was started on an intravenous antibiotic, levofloxacin, without prior notification to hospice. The hospice VP confirmed that hospice was not notified until several days after the midline was placed and the intravenous antibiotic was administered. Additionally, the order for doxycycline was never transcribed to the electronic medical record. The clinical record review indicated that Resident C had diagnoses including obstructive uropathy, diabetes, and polymyalgia rheumatica, and was cognitively intact as per a quarterly MDS assessment. The hospice service agreement required that any changes in the plan of care be discussed and approved by hospice before implementation. The Director of Nursing acknowledged that hospice should have been notified before starting the levofloxacin. The failure to notify hospice and the lack of transcription of the doxycycline order led to a deficiency in the coordination of care for Resident C.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 891 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Southport | 0.7 mi | ★★★★★ | 5 | 0 |
| Southpointe Healthcare Center | 1.3 mi | ★★★★★ | 13 | 0 |
| University Heights Health And Living Community | 1.7 mi | ★★★★★ | 3 | 0 |
| Greenwood Health And Living Community | 2.1 mi | ★★★★★ | 5 | 0 |
| Rosegate Village | 2.3 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.