Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Hillcrest Village during CMS and state inspections, most recent first.
Surveyors found that the facility failed to accurately document narcotic medication administration on MARs for several residents. Controlled substance records showed multiple administrations of PRN and scheduled narcotic pain medications and an anti-anxiety medication, but these doses were not consistently recorded on the corresponding MARs. An LPN reported that narcotics should be documented on both the controlled substance record and the MAR, and facility procedures required recording administration on the EMAR after giving medications, yet this did not occur for multiple documented doses.
QMAs failed to practice within their scope when administering PRN narcotic pain medications and performing advanced wound care. A resident with chronic pain and another with diabetes and depression received PRN narcotic analgesics from a QMA without documented RN/LPN assessment, nurse authorization, or nurse initials on the controlled substance records, despite facility policy requiring nurse assessment and co-signature for PRN administration. In addition, a resident with a stage 4 sacral pressure ulcer had complex wound treatments and wound monitoring signed off by QMAs, even though the facility’s QMA scope of practice prohibits QMAs from providing treatments for stage II–IV pressure ulcers or independently assessing residents’ conditions.
A resident with hypotension had a physician order for Midodrine 5 mg three times daily with instructions to hold the dose if systolic BP was greater than 140. Review of the MAR showed the resident was given Midodrine on two occasions when systolic BP readings were above this parameter. An LPN acknowledged that BP medications should not be given outside ordered parameters, and the DON stated there was no facility policy addressing medication parameters.
The facility failed to ensure ordered wound and pressure ulcer treatments were consistently provided and accurately documented for three residents with Stage 4 pressure ulcers and other chronic wounds. One resident with a sacral Stage 4 ulcer reported that night-shift wound care was not performed, even though an RN had signed the TAR; a subsequent dressing check showed the prior day-shift dressing still in place. Another resident with heel and buttock wounds had missing TAR documentation for several shifts and reported that a buttock wound treatment was not done, while the dressing in place matched the prior day-shift application despite the TAR indicating completion by night shift. A third resident with a coccyx/sacral Stage 4 ulcer had multiple shifts with no TAR documentation of the ordered every-shift wound care.
Failure to Prime Insulin Pen Needle Before Administration: An LPN obtained a resident’s blood sugar, dialed an insulin pen to the ordered dose without a needle attached, then added the needle but did not prime it before administration. The dose was stopped, the pen was primed, and the insulin was then given. The resident had type 2 DM with hyperglycemia, and the order was for rapid-acting insulin three times daily per sliding scale.
Failure to prevent a bed bath fall: A resident with diabetic neuropathy, repeated falls, weakness, and limited mobility fell from the bed while two CNAs were providing care. The resident was turned onto his side with his legs crossed, slipped off the bed, and sustained a bruise, skin tear, abrasions, and scratch marks. RN and DON interviews confirmed the resident could not move well on his own and that the bedside CNA should have been positioned to catch him.
Glucometers were not cleaned per infection control guidance after blood sugar checks for two residents. A QMA left a glucometer on the med cart without cleaning it, then used an alcohol wipe instead of the required bleach wipe. An LPN also cleaned a glucometer with an alcohol wipe after a blood sugar check and later used a Clorox wipe for only 30 seconds, while the competency instructions stated alcohol preps should not be used and bleach germicidal wipes should be used for 3 minutes.
A resident with traumatic brain injury, anoxic brain damage, schizophrenia, and quadriplegia was physically abused by a CNA during a transfer to bed. While assisting with care, the resident punched and spat on the CNA and verbally insulted her, after which the CNA, by her own account and corroborated by another CNA, became angry and struck the resident on the right side of the face multiple times with an open hand, including hitting the resident in the mouth. Subsequent assessment documented scratches to the resident’s forehead and right brow and a swollen, discolored upper lip. These actions occurred despite a facility policy that prohibits willful physical abuse such as hitting or slapping residents.
The facility did not ensure that the administration of narcotic medications was properly documented in the MARs for three residents, despite records showing the medications were given. Staff confirmed that documentation should occur at the time of administration, and facility policy requires recording in both the MAR and controlled substances inventory, but this was not followed.
Blood pressure medications were administered to two residents with hypotension despite physician orders to hold the medication for out-of-parameter systolic blood pressure readings. An LPN confirmed that medications should not be given when blood pressure is outside the specified range, but records showed multiple instances where midodrine was administered contrary to orders.
A resident with multiple health conditions requiring assistance with ADLs did not consistently receive scheduled showers. The care plan specified two showers per week, but records showed multiple instances of missing documentation, indicating showers were not provided. Interviews with the resident and staff confirmed the deficiency, with staff acknowledging that blank shower sheets meant showers were not given.
Two residents experienced delays in receiving their prescribed medications due to issues with pharmacy services and medication availability. One resident, with chronic respiratory and pain conditions, missed multiple doses of Percocet, while another resident with acute respiratory failure and other conditions faced delays in receiving scheduled antibiotics. Staff interviews highlighted that medications should not take days to arrive, yet the facility encountered significant delays despite having 24-hour pharmacy access.
A resident with hypertension and hemiparesis experienced multiple instances of elevated blood pressure readings over several months, which were not communicated to the physician as required by the facility's policy. Despite the resident's blood pressure consistently exceeding the acceptable range, the clinical record lacked evidence of physician notification. A Nurse Practitioner confirmed that such changes should have been reported immediately.
A facility failed to conduct a self-administration assessment for a resident, resulting in medications being left at the bedside without proper authorization. The resident, with a history of hypertension, hemiparesis, hemiplegia, and diabetes, was observed with morning medications on the bedside table. Interviews confirmed the absence of a self-administration assessment or physician's order, contrary to facility policy.
A resident with a history of hypertension and CVA experienced consistently high blood pressure readings without adequate follow-up or rechecks by the facility. Despite a care plan that included monitoring and medication administration, the resident frequently refused medication and called 911 due to feeling unwell. Interviews with staff revealed the resident's noncompliance with the medication regimen, and the facility failed to implement sufficient monitoring or interventions to address the resident's condition effectively.
A facility failed to accurately document medication administration for a resident with hypertension and diabetes. The MAR lacked records for metformin and hydralazine on several occasions, and a one-time clonidine order was not documented. An LPN confirmed the requirement to sign off medications on the MAR, and the DON provided a procedure document emphasizing this practice.
A resident reported an incident of verbal abuse by an LPN to another LPN, who informed the Executive Director. However, the Executive Director claimed no such report was made, and the facility failed to document or report the incident to the Indiana Department of Health as required by their policy.
A facility failed to document a resident's blood pressure before administering Clonidine, a medication for hypertension, as required by the physician's order. The resident's blood pressure was not recorded on several occasions, and there was no explanation for withholding the medication on one occasion. An LPN confirmed the necessity of documenting blood pressure when parameters are in place, highlighting a procedural lapse.
Failure to Accurately Document Narcotic Medication Administration on MARs
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of accurate medication administration records for multiple residents receiving narcotic medications. For one resident with osteomyelitis and necrotizing fasciitis, the controlled substance record showed multiple administrations of PRN Oxycodone-Acetaminophen on specific dates and times in March and April 2026, but the corresponding MARs for those months lacked documentation of these administrations. An LPN stated that narcotic medications should be documented both on the controlled substance record and the MAR, indicating that this dual documentation did not occur as required. Similar documentation gaps were found for three additional residents. One resident with rheumatoid arthritis and chronic pain syndrome had several administrations of PRN Oxycodone recorded on the March 2026 controlled substance record, but these doses were not documented on the March MAR. Another resident with multiple sclerosis and generalized anxiety had scheduled Oxycodone-Acetaminophen doses and Lorazepam doses missing from the March MAR on specific dates and times. A fourth resident with diabetes, depression, and peripheral vascular disease had multiple administrations of PRN Hydrocodone-Acetaminophen documented on the April 2026 controlled substance record, but none of these were recorded on the April MAR. The facility’s written procedure stated that medication administration would be recorded on the EMAR after being given, but the survey findings showed that this did not occur consistently for these narcotic medications.
QMAs Functioning Outside Scope for PRN Narcotics and Stage 4 Wound Care
Penalty
Summary
The deficiency involves failure to ensure qualified medication aides (QMAs) practiced within their defined scope and that care was provided by qualified persons according to each resident’s written plan of care. For one resident with rheumatoid arthritis, chronic pain, and osteoarthritis, a physician’s order directed PRN oxycodone 5 mg every 4 hours for pain. Documentation showed that a QMA administered the PRN narcotic, but the clinical record lacked evidence of a licensed nurse’s initials on the controlled substance record, a documented nursing assessment prior to administration, and documented permission from a licensed nurse, contrary to facility practice as described by an LPN. For another resident with a stage 4 sacral pressure ulcer, the physician’s order required cleansing with normal saline, packing with Dakin’s-soaked gauze, and covering with an ABD pad twice daily, and a separate order required monitoring the sacral wound for signs of infection or decline. The treatment administration record showed QMAs signed off as having completed the stage 4 wound treatment and the monitoring of the stage 4 sacral wound, despite the QMA scope of practice prohibiting them from performing treatments involving stage II–IV pressure ulcers. A third resident with diabetes and major depression had a physician’s order for PRN hydrocodone-acetaminophen 5-325 mg every 8 hours for pain. Records indicated a QMA administered the PRN narcotic, but the clinical record again lacked documentation of a licensed nurse’s initials on the controlled substance record, a nursing assessment prior to administration, and documented permission from a licensed nurse. The facility’s QMA Parameters and Scope of Practice, provided by the DON, specified that QMAs may not assess a resident’s condition and may administer previously ordered PRN medications only after contacting a licensed nurse, documenting the contact, symptoms, permission, and time, and ensuring the record is co-signed by the nurse by the end of the shift or next tour of duty. The same scope document also stated that QMAs may not administer treatments involving advanced skin conditions, including stage II, III, and IV pressure ulcers. These documented practices and omissions show that QMAs performed tasks outside their authorized scope and without required licensed nurse assessment and documentation.
Failure to Hold Midodrine When Blood Pressure Exceeded Ordered Parameters
Penalty
Summary
A resident with a diagnosis that included hypotension had a physician’s order, dated 3/3/26, for Midodrine 5 mg to be administered three times daily at 7:00 a.m., 11:00 a.m., and 4:00 p.m., with instructions to hold the medication if the systolic blood pressure was greater than 140. Review of the March 2026 medication administration record showed that the resident received Midodrine on two occasions when the systolic blood pressure exceeded the ordered parameter: once with a systolic blood pressure of 157 and once with a systolic blood pressure of 150. In an interview, an LPN stated that blood pressure medications should not be administered if they are not within the physician-ordered parameters, and the DON reported that the facility did not have a policy related to medication parameters. These findings demonstrate that the facility failed to ensure the resident’s blood pressure medication was held when the blood pressure was out of the ordered parameters for one of five residents reviewed for quality of care.
Failure to Provide and Accurately Document Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pressure ulcer and wound care every shift and to accurately document wound treatments on the treatment administration record (TAR) for multiple residents with Stage 4 pressure ulcers and other chronic wounds. For one resident with a Stage 4 sacral pressure ulcer, the physician ordered wound cleansing with normal saline, application of bacitracin, packing with Dakin’s-moistened gauze, skin prep to the peri-wound, and coverage with a bordered dressing every shift. An anonymous complaint alleged that this resident repeatedly requested night-shift wound care from a specific RN, who did not perform the treatment. Although the April TAR showed the treatment as completed by that RN on a specific night, a CNA reported the resident’s concern that the treatment had not been done, and another RN later confirmed that the dressing in place was still the one applied by the prior day-shift nurse, indicating the night-shift treatment had not been completed as documented. Another resident with a chronic non-pressure ulcer of the left heel and mid-foot and a Stage 4 pressure ulcer to the left buttock had physician orders for heel wound care with betadine and Optifoam every shift, and for buttock wound care with cleansing, packing with normal saline–moistened gauze, skin prep, and a bordered dressing every shift. The March TAR lacked documentation of completed heel wound treatments on two specified shifts, and the resident later reported that the buttock wound treatment was not completed on a particular night. A CNA relayed this concern to an RN, who found that the dressing in place was still the one applied by the prior day-shift nurse, despite the April TAR indicating the night-shift RN had completed the treatment. A third resident with a Stage 4 coccyx/sacral pressure ulcer had orders for wound cleansing with normal saline, peri-wound skin prep, packing with Dakin’s-soaked gauze, and coverage with an ABD pad and tape every shift; review of the March and April TARs showed multiple shifts with no documentation of completed wound treatments. A nurse interview confirmed that nurses are expected to sign the TAR when they complete wound treatments.
Failure to Prime Insulin Pen Needle Before Administration
Penalty
Summary
The facility failed to ensure nursing staff primed the insulin pen needle before dialing and administering the ordered dose during an insulin administration for Resident 53. During observation, an LPN obtained the resident’s blood sugar reading of 135 mg/dL and dialed the Fiasp FlexTouch pen to 25 units without a needle attached. After an RN verified the dose, the needle was added to the pen, but the LPN did not prime the needle before giving the insulin. The LPN was stopped before injecting the medication, then dialed the pen back to zero, primed the needle by expressing 3 units, redialed to 25 units, and administered the insulin. Resident 53’s record showed diagnoses including type 2 diabetes mellitus with hyperglycemia. The care plan identified the resident as at risk for adverse effects of hyperglycemia or hypoglycemia related to glucose-lowering medication and/or diabetes mellitus, and included administering medications as ordered. The physician’s order directed staff to administer 25 units of Fiasp FlexTouch insulin subcutaneously three times daily per sliding scale. The DON stated the only policy located for priming insulin needles was the Administration of Medications policy, and the corporate policy for priming insulin needles stated insulin pens must be primed before every injection.
Failure to Prevent a Bed Bath Fall
Penalty
Summary
The facility failed to ensure fall prevention was maintained for a resident with muscle weakness and repeated falls when the resident fell from the bed during a bed bath. The resident had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, bilateral hearing loss, chronic pain, and repeated falls. The care plan identified the resident as at risk for falls due to repeated falls, unsteady gait, need for a mechanical lift for transfers, lack of understanding of cognitive and physical limitations, decreased mobility, and weakness. A nurse note documented that while two staff members were providing a bed bath and the resident was turned to the right side/stomach with the feet crossed, the resident’s feet slipped off the side of the bed and pulled the resident to the floor. After the fall, the resident sustained a bruise to the back of the right arm, a long skin tear down the left shin, abrasions to both knees, and scratch-like marks to the abdomen. The interdisciplinary team note stated that two staff were giving the bed bath when the resident was turned onto the right side and the legs slid off the side of the bed. During interview, RN 3 stated that one CNA turned to get bath supplies while the other was by the bed, and the CNA at the bedside should have been there to catch the resident because he could not move well on his own. The DON stated the resident already had his legs crossed when staff turned him over and there was momentum that caused the resident to roll out of bed.
Glucometers Not Cleaned Per Infection Control Guidelines
Penalty
Summary
The facility failed to ensure glucometers were cleaned according to infection control guidelines after blood sugar checks for two residents. During an observation, a QMA obtained a resident’s Accu check, left the room, placed the glucometer on the medication cart, and did not clean it. When the QMA was about to check another resident’s blood sugar, she was stopped because the glucometer had not been cleaned; she then rubbed it with an alcohol wipe for 20 seconds. During interview, the QMA stated she should have cleaned the glucometer after every room and indicated she had used an alcohol wipe instead of the bleach wipe required by the instructions on the medication cart. Later the same day, an LPN obtained one resident’s blood sugar and administered insulin, then cleaned the glucometer with an alcohol wipe for about 30 seconds. When the LPN later checked another resident’s blood sugar, she stated she had used an alcohol wipe to clean the glucometer and believed alcohol was just as good as bleach. She then cleaned it with a Clorox wipe for 30 seconds and laid it on the cart to dry. The DON stated nursing staff could use either an alcohol wipe or a bleach wipe and should rub or wrap the glucometer for 1 minute and let it dry for 3 minutes, while the glucometer competency instructions stated not to use alcohol preps and to use bleach germicidal wipes for 3 minutes.
Staff-to-Resident Physical Abuse During Transfer
Penalty
Summary
The facility failed to protect a resident from staff-to-resident physical abuse when a CNA intentionally struck the resident during care. The resident involved had significant medical conditions, including traumatic brain injury, anoxic brain damage, schizophrenia, and quadriplegia, and was observed on a later date resting in a reclining high-back wheelchair, well groomed and without visible facial injuries. According to an incident report and subsequent wound assessments from the date of the event, the resident sustained a right forehead scratch measuring 2 cm by 0.1 cm, a right eyebrow scratch measuring 0.1 cm by 0.5 cm, and a swollen area of the right upper lip measuring 0.3 cm by 1.8 cm, all without depth. During a telephone interview, the CNA admitted that while assisting with transferring the resident to bed, the resident punched her in the face and spat on her multiple times, after which she became angry and smacked the resident on the right side of the face before leaving the room and self-reporting the incident to the Executive Director. Another CNA who assisted with the transfer reported that the resident cursed at and verbally insulted the first CNA, which appeared to trigger her, and that the CNA then approached and smacked the resident multiple times with an open hand on the right side of the face. The second CNA further stated that before she could intervene, the resident spat on the first CNA, who then struck the resident again in the mouth with an open hand. The Unit Manager later assessed the resident and confirmed the presence of a scratch to the forehead, a scratch near the right brow, and a swollen, discolored upper lip. These actions occurred despite the facility’s written abuse policy, which prohibits physical abuse and defines it as a willful act such as hitting or slapping a resident.
Failure to Document Narcotic Medication Administration in MARs
Penalty
Summary
The facility failed to ensure that medication administration records (MARs) accurately reflected the administration of narcotic medications for three residents. For one resident with diagnoses including anxiety, diabetes, and chronic pancreatitis, the MAR did not document the administration of prescribed Xanax and oxycodone, despite the controlled substance record indicating these medications were given on multiple occasions. Similarly, another resident with depression and rheumatoid arthritis received Tramadol as documented in the controlled substance record, but the administration was not recorded in the MAR for both March and April. A third resident with a left femur fracture and osteoarthritis was administered hydrocodone-acetaminophen, as shown in the controlled substance record, but the MAR lacked corresponding documentation. Interviews with staff confirmed that the MAR should be signed when narcotic medications are administered. The Director of Nursing provided a policy stating that administration of controlled substances must be recorded in both the MAR and the controlled substances inventory record at the time of administration. Despite this policy, the required documentation was missing from the MARs for all three residents, as observed during the review.
Failure to Hold Blood Pressure Medication per Physician Orders
Penalty
Summary
The facility failed to ensure that blood pressure medications were held according to physician-ordered parameters for two residents diagnosed with hypotension. For one resident, midodrine was ordered to be held if the systolic blood pressure (SBP) exceeded 135 mmHg or diastolic blood pressure (DBP) exceeded 85 mmHg. Despite this, the medication was administered when the resident's SBP was 142 mmHg. An LPN confirmed during interview that blood pressure medications should not be given when readings are outside the specified range. For another resident, midodrine was ordered to be held if the SBP was greater than 140 mmHg. The medication administration record showed multiple instances where midodrine was administered despite SBP readings ranging from 144 to 151 mmHg. These actions were not in accordance with the physician's orders and the residents' clinical needs as documented in their records.
Inconsistent Shower Provision for Resident
Penalty
Summary
The facility failed to consistently provide showers for Resident 84, who was reviewed for Activities of Daily Living (ADL) care. Resident 84 had multiple diagnoses, including Parkinson's disease, spinal stenosis, type 2 diabetes mellitus, and reduced mobility, which necessitated staff assistance for ADL tasks. The care plan for the resident, dated 9/6/24, specified that the resident should receive two showers per week, with partial baths in between, and assistance with other ADL tasks as needed. However, a review of the resident's shower report records revealed multiple instances in December 2024 where documentation was lacking, indicating that the resident did not receive the scheduled showers. Interviews with the resident and staff members confirmed the deficiency. The resident reported not receiving the showers as scheduled, stating she was supposed to get two showers a week but was lucky to get one. Certified Nursing Aides (CNAs) and a Licensed Practical Nurse (LPN) confirmed that the shower sheets were supposed to be checked off when showers were given, and if the sheets were blank, it meant the showers were not provided. The Director of Nursing (DON) also indicated that staff should document on the shower report sheet when a shower was given and what care was provided.
Medication Administration Delays for Two Residents
Penalty
Summary
The facility failed to ensure that two residents received their medications as ordered and in a timely manner. Resident 62, who had diagnoses including acute and chronic respiratory failure, COPD, asthma, and chronic pain, did not receive their prescribed Percocet on multiple occasions due to issues with medication availability and prior approval requirements. The resident's care plan emphasized the importance of administering pain medications as ordered, yet there were repeated instances where the medication was unavailable, and the pharmacy was notified but did not provide the medication promptly. The Director of Nursing acknowledged the challenges with obtaining prior approvals and indicated that medications should not take more than a few hours to a day to be delivered. Resident 64, diagnosed with acute respiratory failure, atrial fibrillation, cardiomegaly, type 2 diabetes, hypertension, and chronic pain, also experienced delays in receiving their scheduled antibiotic treatment. The resident's vascular access was replaced, and a scheduled dose of meropenem was administered late. Additionally, three doses of IV antibiotics were missed, and the pharmacy was informed of the need to extend the order due to these missed doses. The facility's Emergency Drug Kit did not have the correct dose available, and the reconstitution was out of stock, further delaying the administration of the medication. Interviews with facility staff, including an LPN, revealed that medications should not take days to arrive and that the facility had access to pharmacy services 24 hours a day. Despite having a backup pharmacy, the facility experienced significant delays in obtaining necessary medications, impacting the timely administration of prescribed treatments for the residents involved.
Failure to Notify Physician of Resident's Out-of-Range Blood Pressure
Penalty
Summary
The facility failed to notify the physician when a resident's blood pressure readings were outside the established parameters. Resident B, who had a history of hypertension and left-sided hemiparesis secondary to a cardiovascular accident, experienced multiple instances of elevated blood pressure readings over several months. These readings were consistently above the acceptable range set for the resident, with systolic pressures reaching as high as 200 mmHg and diastolic pressures exceeding 100 mmHg on numerous occasions. Despite these out-of-range blood pressure readings, the clinical record did not show any evidence that the physician was notified of these changes in the resident's condition. During an interview, a Nurse Practitioner confirmed that such high or low blood pressures should be considered a change in condition, warranting immediate notification to the physician. The facility's policy on resident change of condition, which mandates communication with the physician for any changes, was not adhered to in this case.
Failure to Conduct Self-Administration Assessment for Resident Medications
Penalty
Summary
The facility failed to ensure that medications for a resident, identified as Resident B, were not left at the bedside without a self-administration assessment. Resident B, who has a medical history including hypertension, left-sided hemiparesis, hemiplegia secondary to a cerebral vascular accident (CVA), and diabetes, was observed with a medication cup containing six tablets/capsules on her bedside table. These medications were scheduled to be administered between 7:00 a.m. and 11:00 a.m. and included Amlodipine, Aspirin, Clopidogrel, Metformin, Metoprolol, and Hydralazine. However, there was no documentation in the clinical record of a self-administration medication assessment or a physician's order allowing Resident B to self-administer these medications. During interviews, an LPN confirmed that Resident B did not self-administer medications and that the medications observed were her morning doses. The Director of Nursing also confirmed that Resident B did not have a medication self-administration assessment. The facility's policy on self-administration of medications, dated January 2015, requires an interdisciplinary team assessment and a physician's order for a resident to self-administer medications. This deficiency was identified during a complaint investigation related to Resident B.
Failure to Monitor and Intervene for Resident with High Blood Pressure
Penalty
Summary
The facility failed to ensure increased monitoring and interventions for a resident with consistently high blood pressure and a history of cardiovascular accident. The resident, diagnosed with hypertension and CVA with left-sided hemiparesis, had a care plan that included various interventions such as medication administration, monitoring vital signs, and notifying the physician of any changes. Despite these interventions, the resident's blood pressure readings were frequently out of the acceptable range, and there was a lack of follow-up or documented rechecks for these elevated readings. The resident often refused the prescribed hydralazine medication, believing it was too strong, and this refusal was communicated to the nurse practitioner. The resident's blood pressure remained high, leading to multiple instances where the resident called 911 due to feeling unwell. The facility's records showed numerous instances of elevated blood pressure readings without appropriate follow-up or rechecks, indicating a failure to adequately monitor and address the resident's condition. Interviews with facility staff, including an LPN and a nurse practitioner, revealed that the resident was noncompliant with the medication regimen, often refusing medications and calling emergency services instead. The nurse practitioner noted the resident's noncompliance and did not make changes to the medication regimen, considering the resident's refusals as non-compliance. Despite the resident's high blood pressure readings and frequent calls to emergency services, the facility did not implement sufficient monitoring or interventions to address the resident's condition effectively.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident diagnosed with hypertension and diabetes. The resident's care plan required the administration of metformin and hydralazine as ordered by the physician. However, the Medication Administration Record (MAR) for October 2024 lacked documentation of metformin administration on two occasions and hydralazine on multiple occasions. Additionally, a one-time order for clonidine was not documented in the MAR, indicating a failure to record the administration of this medication. During an interview, an LPN confirmed that medications should be signed out on the MAR once administered, and one-time orders should be entered and signed off in the electronic medical record. The Director of Nursing provided a document outlining the medication administration procedure, which emphasized the need for recording medication administration on the MAR after it is given. This deficiency was identified during a complaint investigation, highlighting lapses in the facility's medication administration documentation process.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility management failed to report an incident of alleged verbal abuse involving a resident, identified as Resident B, to the Indiana Department of Health. Resident B, who was alert and oriented, reported having multiple negative interactions with an LPN, specifically mentioning an incident where the LPN became aggressive after a request for pain medication. The LPN allegedly called Resident B a 'smart a**,' to which Resident B responded in kind. This incident was reported by Resident B to another LPN, who then informed the Executive Director (ED). However, the ED indicated that no such report was made to him, and the facility's records for June 2024 did not document this allegation of verbal abuse. The facility's policy, titled 'Abuse Prohibition, Reporting, and Investigation,' mandates that all abuse allegations must be reported to the ED immediately and to the Long-Term Care Division of the Indiana Department of Health within two hours. Despite this policy, the facility did not provide any additional information related to the incident, and the required report was not made. This deficiency was identified during a review of the facility's handling of the complaint, which was related to Complaint IN00436365.
Failure to Document Blood Pressure Before Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's blood pressure was obtained prior to the administration of Clonidine, a medication prescribed for hypertension. The clinical record for Resident D, who has diagnoses including cardiovascular disease and hypertension, was reviewed. The physician's order specified that Clonidine 0.1 mg should be administered every six hours, with the condition that it should be held if the systolic blood pressure was less than 100. However, on multiple occasions in June 2024, the medication was administered without documenting the resident's blood pressure. Additionally, on June 8, 2024, the Clonidine was not administered as it was on hold, but there was no documentation explaining why the medication was withheld. During an interview, an LPN confirmed that blood pressure should have been documented and obtained prior to medication administration when parameters are in place. The Director of Nursing provided a document titled Medication Administration, which included the requirement for obtaining vital signs if necessary, indicating a procedural lapse in this instance.
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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 Jeffersonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverview Village | 1.3 mi | ★★★★★ | 1 | 0 |
| Home Of The Innocents | 2.2 mi | ★★★★★ | 37 | 0 |
| Chestnut Ridge Health & Rehabilitation | 2.5 mi | ★★★★★ | 3 | 2 |
| Clark Rehabilitation And Skilled Nursing Center | 2.6 mi | ★★★★★ | 3 | 0 |
| Clifton Heights | 2.8 mi | ★★★★★ | 11 | 1 |
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