Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Signature Healthcare Of Terre Haute during CMS and state inspections, most recent first.
A staff member failed to follow a resident’s care plan requiring a gait belt for transfers and instead lifted him by his pants and under his arm. The resident, who had left-sided hemiparesis, blindness in one eye, and a history of falls, lost his balance, fell to the floor, and later was found to have an acute clavicle fracture requiring ED evaluation. The record also lacked a valid progress note for the fall.
The facility failed to ensure critical and STAT lab results were communicated and documented according to policy for two residents. One resident with COPD, diabetes, and hypertension had critical hemoglobin results reported to the facility after a prior hospitalization for low hemoglobin, but there was no documentation that the physician was notified of these abnormal labs. Another resident with advanced dementia had STAT labs ordered twice for a change in condition and increased pain; when the lab could not send a technician and the resident refused hospital labs, there was no documentation that the practitioner or responsible party were notified, nor that subsequent STAT labs not obtained were reported. Staff interviews and facility policy confirmed that such changes in condition and lab issues were expected to be communicated and documented in the EMR.
A resident with COPD, unspecified dementia, and a care plan identifying risk for malnutrition repeatedly requested larger meal portions but continued to receive regular portions despite a physician’s order for a regular diet with double portions. Observation of a lunch tray and review of the meal ticket showed no indication or provision of double portions, and dietary staff were unclear about portion notations such as “2 HLF” and “4 HLF.” The RD acknowledged that meal tickets did not clearly reflect portion sizes or special resident choice meals, resulting in the resident’s preference and ordered double portions not being followed.
Surveyors found that the facility failed to notify a cognitively impaired resident’s healthcare representatives of multiple significant events, including diagnostic test results, STAT lab orders that could not be completed, medication changes, new orders, abnormal labs, and a fall, with no documentation of required notifications despite facility policy and staff statements that such notifications should occur. In a separate case, a resident with COPD, HTN, CAD, prior MI, and history of venous thrombosis/embolism did not receive ordered doses of azithromycin and Xarelto when the medications were unavailable, and the record lacked evidence that the physician was notified of the missed doses or unavailability, contrary to the facility’s medication policy.
A resident with multiple complex medical conditions was admitted after a hospital stay, but the facility did not complete a nursing admission assessment, physical and skin assessments, or a baseline care plan within the required 48-hour timeframe. The DON confirmed the absence of timely documentation, which was not consistent with facility policy.
A newly admitted resident with multiple complex medical conditions did not receive a nursing admission assessment, timely wound assessments, or admission orders for respiratory medications and catheter care. Documentation of vital signs and nursing progress notes was delayed, and necessary care orders were not entered until several days after admission, resulting in a lack of quality care upon admission.
Incomplete informed consent for psychotropic medications: Multiple residents receiving psychotropic meds, including antipsychotics, antidepressants, and antianxiety agents, had records that did not show consent for all ordered meds. One resident with anxiety, depression, and bipolar disorder had consent for only some psychotropics, another cognitively intact resident had consent for buspirone only, and other residents with depression, dementia, anxiety, and psychosis also lacked documentation showing informed consent for all psychotropic orders.
Resident Council members were not informed of how to contact the State to file a complaint, and meeting minutes for multiple months lacked documentation that this information had been shared. During interview, the Resident Council President was unsure of the process and a second resident stated he had never been told how to contact the State. The Activity Director said the topic had not been covered in council meetings and she assumed members already knew where the information was located.
Inaccurate MDS coding affected multiple residents. One resident with an indwelling Foley catheter was coded as always incontinent instead of not rated, another resident on hospice was coded as having no terminal prognosis, a third resident was coded with schizophrenia despite records showing psychotic disorder, and a fourth resident’s MDS failed to document a non-pressure wound despite wound care orders and diagnoses. The MDS Coordinator and Regional Clinical Consultant confirmed several of the assessments were coded incorrectly.
A resident with blindness, cognitive impairment, and a prior femur fracture had repeated bed falls with several event forms left blank for new interventions and multiple progress notes lacking root cause analysis or documented prevention measures. The record showed inconsistent fall documentation, changing interventions such as bed placement, non-skid strips, a fall mat, and a body pillow, and notes that did not document refusals of the body pillow. The facility also failed to ensure safe bus transport, as the bus was observed accelerating quickly and failing to stop at a stop sign, while four residents reported feeling jolted, unsafe, or afraid during rides; one resident with bilateral below-knee amputations had a care plan that did not address wheelchair-related fall prevention.
Failure to notify the MD of repeated high BS readings for a resident with diabetes. The resident had multiple glucose values over 400 and one HI reading, but the chart lacked documentation that the MD reviewed or addressed the elevations. The DON acknowledged the notification parameter had not been carried forward, and the Medical Director stated he did not recall being called about the resident’s high BS levels.
The facility failed to complete timely AIMS monitoring for three residents receiving psychotropic medications. One resident with bipolar disorder was on Rexulti, another resident with depression and dementia was on amitriptyline, and a third resident with depression and dementia was on quetiapine. Records showed AIMS documentation was missing at admission or after the most recent admission, despite the facility’s stated monitoring process for psychotropic meds.
Pharmacy review and physician notification were not completed for a resident with depression, dementia, and diabetes. The record showed a pharmacy recommendation for a magnesium level that was not documented as completed or reported to the MD, and a mental health provider recommendation to consider a GDR of amitriptyline was also not documented as being communicated to the physician. The facility policy required the consultant pharmacist to review each resident’s medication regimen and chart at least monthly and for recommendations to be acted upon within 30 days or per facility protocol.
Medication error rate exceeded 5% during an observed med pass, with 3 errors in 27 opportunities. One resident received propranolol that did not match the current order, and two residents received insulin lispro via pen without the pen being primed. In both insulin cases, meals were served well after the rapid-acting insulin was given, and the RCC stated meals should have been served within 15 minutes and the pen primed before each injection.
Infection control practices were not maintained during blood glucose checks when an RN handled a glucometer and resident care items without proper disinfection between residents, placed the device on resident beds without a barrier, and touched a communal strip container with gloves used on a resident. The facility also failed to keep a resident’s Foley catheter tubing off the floor and floor mat during multiple observations, despite orders for an indwelling catheter and catheter care.
A dietary staff member was seen preparing peanut butter and jelly sandwiches without gloves, directly handling bread with bare hands before being stopped by the Dietary Manager. The sandwiches were intended for about ten residents, and facility policy requires glove use and hand hygiene during food preparation.
Staff failed to administer scheduled morphine doses as ordered for a resident with multiple chronic conditions, withholding medication based on their own observations and family input without completing required nursing assessments or notifying the physician. Documentation did not reflect appropriate assessment or physician contact when scheduled doses were omitted.
A resident with Alzheimer's disease and a history of aggressive and wandering behaviors was not provided with individualized interventions or consistent monitoring, despite known risks. The resident entered another resident's room unsupervised, resulting in physical harm to both individuals, including significant injuries and subsequent death. Care plans were not updated to reflect the resident's behaviors, and staff monitoring was insufficient to prevent the incident.
A resident with a history of aggressive behavior was seen leaving another resident's room immediately before the latter was found on the floor with serious injuries, including a clavicle fracture and subdural hematoma. Despite staff observations, statements from the injured resident, and concerns raised by family and hospital staff, the facility did not report the incident as suspected abuse within the required timeframe, instead treating it as a fall with injury. The facility's policy required immediate reporting of all alleged abuse, but this was not followed.
A facility failed to issue a 30-day discharge notice for a resident with cognitive impairment and substantial care needs, who was scheduled to be discharged to a motel. The resident and family were not informed of the discharge plans or appeal rights, and the facility's records lacked documentation of proper discharge planning. Staff interviews revealed a lack of communication and coordination regarding the resident's discharge, and the facility did not follow its policy requiring a 30-day notice.
A facility failed to ensure a safe discharge for a resident with significant clinical needs, including catheter care, oxygen use, and wound care. The resident, who was cognitively impaired and required substantial assistance, was scheduled for discharge without a clear plan for post-discharge care. The Social Services Director did not address payor issues or provide necessary education to the resident and family. The facility's discharge planning process was not followed, leading to confusion and potential risk to the resident's health and safety.
A resident with mental health issues experienced verbal abuse from an agency LPN during a behavioral episode. The LPN engaged in a derogatory verbal exchange with the resident, which was witnessed by CNAs. The facility took immediate action to ensure the resident's safety and removed the LPN from the facility.
A facility failed to accurately report a verbal abuse incident involving an LPN and a resident with mental health issues. The resident and LPN exchanged inappropriate remarks, and staff confirmed the LPN's use of foul language. Although the incident was initially reported, the final report inaccurately stated the allegation was unsubstantiated, contradicting the investigation findings.
The facility failed to provide Notice of Transfer/Discharge forms for four residents hospitalized, including those with Alzheimer's, traumatic amputation, encephalopathy, and respiratory failure. The absence of documentation was confirmed by the Administrator and consultants, indicating a systemic issue in the facility's transfer process.
The facility failed to complete and provide bed hold forms to residents or their representatives during hospital transfers. This deficiency affected three residents, including one with Alzheimer's disease and another with a traumatic amputation. The facility's policy required notification of the bed hold policy at admission and during transfers, but this was not followed, as confirmed by interviews with facility staff.
Two residents in the facility did not receive prescribed medications on multiple occasions, and the facility failed to notify the physician of these administration issues. Resident 76, with multiple health conditions, missed several medications, including Ativan and Atorvastatin, without documentation of physician notification. Similarly, Resident 74 did not receive risperidone due to unavailability, and the physician was not informed until days later. The DON confirmed that staff should notify the physician when medications are unavailable, but this protocol was not followed.
The facility failed to notify the Ombudsman of resident transfers to hospitals for three residents during a specified month. A resident with Alzheimer's was transferred to a psychiatric hospital, another with a traumatic amputation expired at a hospital, and a third with encephalopathy and heart failure was transferred multiple times. The facility's policy requires Ombudsman notification for all transfers, but documentation was lacking due to staffing changes.
A facility failed to ensure QMAs adhered to their scope of practice by documenting treatments on a resident's open wounds, which is outside their authorized duties. The resident had multiple medical conditions, including Alzheimer's and stage 3 pressure ulcers. Despite knowing their limitations, QMAs recorded performing treatments on open wounds, as confirmed by interviews and TAR reviews. The facility's consultant acknowledged the breach of state guidelines, which restrict QMAs from treating advanced skin conditions.
A resident with a history of osteomyelitis, muscle weakness, and severe malnutrition developed new pressure wounds due to the facility's failure to consistently apply offloading heel boots as per physician orders. Despite recommendations from wound care services, the resident was observed multiple times without the boots, and the medical record lacked documentation of an updated care plan or resident refusal to wear the boots.
The facility failed to provide adequate hydration for two residents, leading to a deficiency. One resident was observed with dry skin and mouth, with water often out of reach, despite needing total assistance due to severe malnutrition and dementia. Another resident, also with malnutrition and dementia, was found with an empty water cup and expressed thirst. Staff interviews indicated water was provided twice daily, but observations showed this was not consistently followed.
A facility failed to maintain sanitary conditions for a resident's oxygen equipment. The resident's nasal cannula was found in a trash can, and the oxygen tubing was undated and not stored properly. The resident had chronic heart conditions requiring oxygen therapy, but facility records lacked documentation of proper tubing changes. Staff interviews confirmed the need for bagging and dating the equipment, which was not consistently followed.
A facility failed to complete AIMS assessments for a resident on anti-psychotic medication, Zyprexa, who had Alzheimer's, anxiety disorder, and acute kidney failure. Despite the requirement for assessments every six months, none were documented between October 2023 and January 2025. The DON acknowledged the backlog in assessments, and the SCC confirmed the absence of a specific policy, though the facility's policy emphasized compliance with regulations.
The facility failed to date opened medications in four out of five medication carts, including insulin and eye drops for residents with diabetes and glaucoma. This was observed during inspections with the QMA and DNS, despite the facility's policy requiring such medications to be discarded after a specific period once opened.
A facility failed to complete required post-fall assessments for a resident who fell from a wheelchair. Despite a physician's order for 72-hour follow-up assessments, documentation was missing. The resident, with a history of falls and cognitive impairments, had interventions in place, but the fall risk assessment was not updated. Staff acknowledged documentation deficiencies.
A resident with multiple medical conditions, including functional quadriplegia, missed a physician appointment due to the facility's failure to arrange necessary transportation. Despite being rescheduled, the appointment was missed again as the facility did not coordinate transportation, leading to the resident's transfer to a hospital. Interviews revealed a lack of communication and documentation regarding transportation arrangements.
Two cognitively impaired residents were involved in multiple incidents of inappropriate touching, with one resident repeatedly touching another in common areas and private rooms. Despite staff interventions to separate them and conduct 15-minute checks, the behavior continued. The DON was informed but did not ensure adequate measures were taken, and staff were instructed not to document the incidents. The facility's policy on abuse was not followed, leading to a deficiency for failing to protect residents from abuse.
The facility failed to report and document allegations of abuse involving two residents. Staff observed inappropriate behavior by a resident with dementia towards another resident, but the DON did not report the incidents immediately due to technical issues and instructed staff not to document them. The facility's policy required immediate reporting, which was not followed, leading to a deficiency.
The facility failed to investigate and document allegations of abuse involving two residents. Despite multiple observations of inappropriate touching by one resident towards another, the DON did not ensure a thorough investigation or collect written statements from staff. Monitoring documentation was inconsistent, and staff were reportedly instructed not to document the incidents in medical records. The facility's response lacked a comprehensive care plan and effective interventions, leading to a deficiency in resident safety.
A facility failed to provide personalized care for a resident with schizophrenia, leading to multiple altercations with other residents. Despite several incidents, the facility's documentation lacked evidence of interventions to prevent further events. Staff attempted to redirect the resident, but these actions were not part of a comprehensive care plan.
Failure to Follow Transfer Care Plan Led to Resident Fall and Fracture
Penalty
Summary
A facility staff member failed to follow Resident C’s care plan intervention requiring the use of a gait belt for transfers, and the resident fell during a transfer. Resident C was cognitively intact and had diagnoses including left-sided hemiparesis, need for assistance with personal care, and pain in the left ankle and joints of the left foot. His MDS showed he required substantial to maximum assistance with toileting, dressing, transferring, and personal hygiene, used a manual wheelchair, and was frequently incontinent of bowel and bladder. His care plan identified him as at risk for injury related to falls due to left eye blindness, left-side hemiplegia from a stroke, left foot drop, weakness, incontinence, and a history of falls, and it included an intervention dated 3/31/26 directing staff to use a gait belt with all transfers. During the transfer, CNA 2 did not use a gait belt and instead lifted the resident by placing one arm under his right arm and grabbing the back of his pants with the other hand. The resident reported that his knees buckled, he lost his balance, and he fell to the floor landing on his left side. He later reported left shoulder pain, and an X-ray showed an acute left distal clavicle fracture, after which he was sent to the emergency department for further evaluation. The clinical record also lacked a valid progress note regarding the fall on 5/1/26, and CNA 2 stated she had not reviewed the resident’s care sheet and was aware she needed re-education before returning to work.
Failure to Communicate Critical and STAT Lab Results to Practitioner and Responsible Party
Penalty
Summary
The deficiency involves the facility’s failure to ensure critical abnormal laboratory results were promptly reported to the practitioner and to obtain STAT laboratory tests as ordered. For one resident (Resident D), who had diagnoses including COPD, diabetes, and hypertension and was cognitively impaired requiring maximum assistance, the record showed a history of a recent hospital stay related to a critical low hemoglobin level. After returning to the facility with hemoglobin at non-critical levels, blood was drawn again for diagnostic labs on 7/3/25, and critical lab values were reported to the facility at 2:30 p.m. The medical record, however, lacked documentation that the physician was notified of these critical abnormal lab results, despite facility policy requiring documentation of notification or notification attempts to the medical provider in the electronic medical record when there is a change in condition. The deficiency also includes the facility’s failure to obtain STAT labs and to notify the practitioner and responsible party when labs could not be obtained for another resident (Resident Q). This resident had Alzheimer’s disease with late onset, dementia, severe cognitive impairment, and required assistance with daily care needs. STAT labs were ordered on 11/29/25 due to a change in condition and increased pain complaints, but the lab was unable to send a technician to draw blood, and the record lacked documentation that the physician was notified that the labs could not be obtained or that the resident refused to go to the hospital for labs, as well as lacking documentation of notification of the responsible party. STAT labs were again ordered on 1/22/26, and the record again lacked documentation that the physician was notified when the labs were not obtained. Interviews with nursing staff and the DON confirmed expectations that changes in condition, including labs, should be communicated to the provider and responsible party, and the facility’s written policy required such notifications and documentation in the electronic medical record.
Failure to Provide Ordered Double Meal Portions per Resident Preference
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s meal preference for larger portions despite a physician’s order and the resident’s repeated requests. During an initial interview, Resident J reported that he had asked for more food with his meals for quite some time but continued to receive regular, small portions and felt hungry between meals. Observation of his lunch tray showed that he did not receive double portions when compared to a regular tray, and his meal ticket did not document any order for double portions. Record review showed that Resident J had COPD, unspecified dementia with moderate cognitive deficit, required set-up assistance with eating, and was care planned as being at risk for malnutrition, with interventions including meals as ordered by the physician. A physician’s order dated 1/26/26 directed that he receive a regular diet with double portions per his request. Interviews and documentation revealed confusion and lack of clarity in the dietary system for indicating portion sizes and special meal preferences. The Dietary Manager initially stated that the resident’s ticket showed “4 HLF,” which she said meant double portions, while regular tickets showed “2 HLF,” but the observed lunch tray did not reflect double portions, and the resident choice meal tickets did not show any deviation in portion size. Two dietary staff members reported they did not know what “2 HLF” and “4 HLF” meant and indicated that double portions should be explicitly written on the ticket. The Registered Dietician confirmed there was an issue with meal tickets not clearly indicating portion sizes or special resident choice meals, and that the resident’s ticket did not indicate double portions. The facility’s Resident Rights policy stated that residents’ individuality and input through self-determination would be respected, but Resident J’s expressed preference and physician-ordered double portions were not implemented as ordered.
Failure to Notify Responsible Parties and Physicians of Condition Changes and Unavailable Medications
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible parties and physician of significant changes in condition, diagnostic results, medication changes, and incidents, as well as failure to document such notifications. One resident with Alzheimer’s disease, dementia, severe cognitive impairment, and impaired cognition requiring cues and reminders had multiple events in the medical record where no documentation of responsible party notification was present. These events included review of diagnostic testing results, STAT lab orders related to a change in condition and increased pain when the lab could not send a technician and the resident refused hospital labs, medication changes, new orders, a fall in the resident’s room, diagnostic lab reports, orders for additional lab testing and medication discontinuation, and abnormal lab results. The record repeatedly lacked documentation that the resident’s durable POA for healthcare was notified, despite the daughter’s report that neither she nor her sister had been informed of changes in condition, medication changes, or the fall. Staff interviews confirmed that the expectation was to notify the responsible party and physician of changes in condition, labs, and medication changes, particularly for cognitively impaired residents. RNs and the DON stated they would notify the responsible party of any changes in condition, including labs and medication changes, and that cognitively impaired residents would not be considered their own person for notification purposes. The facility’s policy titled “Notification of Change if Condition” required documentation of notification or notification attempts in the electronic medical record and required that the resident and/or representative and medical provider be notified of a change in condition. Despite this policy and staff statements, the medical record for this cognitively impaired resident lacked the required documentation of notifications for multiple significant clinical events. A second deficiency involved failure to notify a physician when ordered medications were unavailable and therefore not administered to another resident. This resident, who had COPD, a history of venous thrombosis/embolism, HTN, CAD, and a history of MI, had orders for azithromycin for COPD and Xarelto for a history of thrombosis/embolism. The MAR showed that the initial 500 mg dose of azithromycin was unavailable and not administered, and there was no documentation that the resident ever received that dose or that the physician was notified of the unavailability. The MAR also showed that Xarelto was unavailable and not administered on two separate days, with no documentation of physician notification. The Clinical Consultant stated that azithromycin was available in the EDK, that the physician should have been notified when medications were not available, and that the nurse should have administered the antibiotic as soon as it arrived, but she could not provide documentation that the antibiotic was given or that the physician was notified. The facility’s “Non-Controlled Medication Orders” policy required nursing to contact the prescriber when delivery of a medication would be delayed or the medication was not available, which was not reflected in the resident’s record.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident following an acute care hospital stay. The resident had multiple diagnoses, including COPD, diabetes mellitus II, atrial fibrillation, end-stage renal disease requiring dialysis, altered mental status, and a history of stroke, and required assistance with personal care. Upon review, the clinical record lacked documentation of a nursing admission assessment, physical assessment, skin assessment, baseline care plan, and catheter assessment until the afternoon of the fourth day after admission. The DON confirmed that there was no documentation regarding the resident's admission in the clinical record, and the baseline care plan was not completed in a timely manner, contrary to the facility's policy requiring completion within 48 hours.
Failure to Complete Admission Assessment and Orders for Newly Admitted Resident
Penalty
Summary
Staff failed to complete a nursing admission assessment, wound assessments, and admission orders for two respiratory medications and a urinary catheter for a newly admitted resident. The clinical record for this resident, who had multiple complex diagnoses including COPD, diabetes, atrial fibrillation, end-stage renal disease requiring dialysis, altered mental status, and a history of stroke, lacked documentation of a nursing admission assessment, including vital signs, skin assessment, and catheter assessment. There was no nursing progress note entered until two days after admission, and vital signs were not documented until two days post-admission. Additionally, orders for necessary respiratory medications and catheter care were not entered until several days after admission. A skin and wound assessment was not completed until two days after admission, at which time multiple pressure injuries and arterial ulcers were identified. The resident was subsequently sent to an acute care hospital due to respiratory distress and other symptoms. The Director of Nursing confirmed the absence of documentation regarding the resident's admission in the clinical record. Facility policy requires that information needed for immediate care, including routine care orders, be provided prior to or at the time of admission, but this was not followed in this case.
Incomplete informed consent for psychotropic medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications for multiple residents whose records were reviewed. The deficiency involved residents receiving medications in several psychotropic categories, including antipsychotics, antidepressants, antianxiety agents, anticonvulsants used as mood stabilizers, and hypnotics, but the records did not consistently show that consent had been obtained for all of the psychotropic medications ordered for each resident. Resident 8 had diagnoses including anxiety disorder, major depressive disorder, and bipolar disorder, and was receiving alprazolam, bupropion, Rexulti, doxepin, and lamotrigine. The record showed a consent dated 8/11/25 for bupropion and alprazolam, but it did not document informed consent for Rexulti, doxepin, or lamotrigine until a later consent dated 9/9/25. The record also lacked documentation that informed consent for psychotropic medications had been obtained from the resident or representative before 8/11/25. Resident 11 was cognitively intact and was receiving quetiapine, buspirone, and duloxetine for anxiety and depression. A consent dated 8/11/25 documented buspirone only and did not include quetiapine or duloxetine. The record lacked documentation of informed consent for psychotropic medications before 8/11/25. During interview, the Regional Clinical Consultant stated there had been issues with the psychotropic medication consents, that consents were initially obtained in August but did not include all required medications, and that all required psychotropic medication consents were completed later in September 2025. Resident 5 had diagnoses including depression, dementia, and diabetes and was ordered amitriptyline for depression, but the record lacked documentation of consent for psychotropic medication. Resident 99 had diagnoses including depression and dementia and was ordered quetiapine for dementia, but the record lacked documentation of psychotropic medication consents from 2/12/25 to 8/8/25. Resident 103 had diagnoses including dementia, anxiety disorder, and psychosis and was receiving olanzapine, Zoloft, and Paxil; the consent dated 8/10/25 documented olanzapine only and did not document consent for Paxil or Zoloft. The consultant stated that the August consents only included antipsychotic medications and did not meet the required guidelines for all psychotropic medications.
Resident Council Not Informed of State Complaint Contact Information
Penalty
Summary
The facility failed to ensure residents were informed of the contact information for how to file a complaint with the State. During review of Resident Council meeting minutes for June, July, and August 2025, there was no documentation that council members had been told where to find information on filing a complaint with the State. During the Resident Council interview, the President stated she was not sure how to contact the State if she had a complaint and could not remember the topic ever being discussed at Resident Council meetings. At the same interview, Resident 76 stated he had never been informed about how to contact the State to file a complaint. The Activity Director stated the facility had not covered how to file a complaint with the State in Resident Council meetings and that she had assumed the members already knew where the information was located. Record review showed the Resident Council President had no cognitive deficit on the annual MDS assessment, and Resident 76 had no cognitive deficit on the admission MDS assessment. The Regional Clinical Consultant stated she could not find a specific policy related to the topics that were supposed to be discussed during Resident Council meetings and that the facility would follow State regulations.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of MDS assessments for 4 of 27 residents reviewed. For Resident 14, the record showed diagnoses including neuromuscular dysfunction of the bladder and urinary retention, and a physician order directed use of an indwelling Foley catheter. However, three quarterly MDS assessments coded the resident as having an indwelling catheter and being always incontinent of urine. During interview, the MDS Coordinator stated that residents with an indwelling catheter should be coded as not rated, and the Regional Clinical Consultant confirmed the assessments were not coded correctly and that the resident had not had leaking from the catheter. The record did not contain documentation supporting catheter leakage. For Resident 15, the record showed a significant change MDS and a quarterly MDS that both marked the resident as having no terminal prognosis. The resident had a physician order for hospice admission, and hospice documentation stated the hospice physician certified a prognosis of less than 6 months if the disease ran its normal course. During interview, the Regional Clinical Consultant stated the MDS assessments were not coded correctly and should have been marked yes because the resident had a terminal prognosis and was on hospice services. For Resident 16, a quarterly MDS coded schizophrenia as the resident’s diagnosis, but the resident’s profile and psychiatric progress note documented psychotic disorder with delusions due to a known physiological condition and did not document schizophrenia. The Regional Clinical Consultant stated the resident did not have schizophrenia and that the MDS was coded incorrectly. For Resident 145, the MDS indicated the resident had a dressing to the foot but did not document a non-pressure wound, despite the medical record showing osteomyelitis, a chronic ulcer of the left foot, an open wound of the left great toe, and a physician order for daily wound care. The facility policy provided by the DON stated that when data is conflicting or appears in error, the MDS Coordinator is to verify the information to ensure accuracy.
Falls and Unsafe Resident Transportation
Penalty
Summary
The facility failed to ensure interventions were initiated after repeated falls for one resident. Resident 16 had diagnoses including blindness in the right eye, mild cognitive impairment of unknown etiology, and a prior fracture of the neck of an unspecified femur. A quarterly MDS dated 8/26/25 indicated the resident was cognitively intact and required substantial to maximal assistance with transfers. The record showed multiple unwitnessed falls from bed on 4/15/25, 4/17/25, 5/8/25, 5/14/25, 6/22/25, and 9/13/25, along with a witnessed slide from bed on 6/26/25 and a witnessed fall on 8/11/25 and 8/24/25. Several fall event forms left the section for a new intervention blank, and multiple progress notes lacked documentation of a root cause analysis or a new intervention to prevent further falls. The documentation showed inconsistent and incomplete follow-up after the falls. After the 4/15/25 and 4/17/25 falls, progress notes described confusion, disorientation, combativeness, and continued decline in status, but no root cause analysis or new intervention was documented. After the 5/8/25 fall, the resident was found on the floor beside the bed, appeared at baseline confusion, and thought he was getting off the truck, yet the note again lacked documentation of a root cause analysis or intervention. After the 5/14/25 fall, the resident was found on the floor with right leg rotation and was sent to the hospital; the fall event form still left the intervention section blank. Later notes described interventions such as moving the bed against the wall, placing non-skid strips on the floor, moving the urinal within reach, encouraging use of the call light, and providing a bariatric bed, but the record also showed that some events were documented differently across notes, including one note describing a witnessed fall when the event form indicated the fall was unwitnessed. The resident continued to have falls and related interventions were revised over time, including a fall mat, enablers for bed mobility, and a body pillow to assist with bed boundaries after the resident was found on the floor and stated, "I was fishing." Progress notes from 9/15/25 to 9/22/25 did not document that the resident refused the body pillow, although the Regional Clinical Consultant stated the resident sometimes refused it. During interview, the consultant acknowledged that the resident's fall interventions needed to be re-evaluated and that the facility had completed a fall audit in August 2025 after discovering issues with the fall program. The facility policy stated that the care plan would be reviewed following each fall and revised as applicable. The facility also failed to ensure safe transport of residents on the facility bus. During observations, the bus was seen backing out of the south parking area at an accelerated rate on 9/16/25 and 9/19/25, and on 9/22/25 it failed to stop at the stop sign at the end of the driveway before entering the municipal street. Residents 132, 76, 145, and 65 each reported feeling unsafe or afraid while riding the bus, describing sudden starts and stops, sharp corners, and fast driving. One resident stated the driver made her feel unsafe at times because she was jolted back and forth, another said he had been tossed back and forth on sharp turns, another refused to ride because the driver drove too fast, and another said he feared falling out of his wheelchair during transport. Resident 65's record showed diagnoses including acquired absence of the right and left lower legs below the knee, and a care plan dated 9/2/25 identified fall risk but did not include documentation of fall prevention when in the wheelchair related to balance issues from bilateral lower leg amputations. The Administrator stated the bus driver should use safe driving practices at all times when transporting residents, and the DON provided the Transportation Policy stating staff using a facility-owned motor vehicle must meet criteria for safe driving.
Failure to Notify Physician of Repeated High Blood Sugars
Penalty
Summary
The facility failed to ensure the physician was notified of elevated blood sugar levels for one resident with diabetes. The resident had a history that included cerebral infarction, COPD, paraplegia, and diabetes, and the record showed repeated high glucose readings, including 506, 401, 406, 442, and a reading of HI. The resident stated that elevated blood sugar levels were related to infections and repeated urinary tract infections. The physician progress notes reviewed in the record did not document that the physician reviewed or addressed the resident’s elevated blood sugar levels. The resident had physician orders for sliding-scale insulin and parameters that required notification of the physician for blood sugar readings over 400, but the DON acknowledged that the order had not been carried forward under the physician’s orders. The Medical Director stated staff should notify him of blood sugar levels above 400 and indicated he did not recall being notified of the resident’s elevated readings; he later reviewed the blood sugars and stated he would make medication adjustments. RN staff stated that blood sugar readings over 400 should be reported immediately, and the facility policy in use required informing and consulting the resident’s physician for significant changes in condition or a need to alter treatment significantly.
Failure to Monitor Residents Receiving Psychotropic Medications
Penalty
Summary
The facility failed to monitor for side effects in residents who were receiving psychotropic medications, specifically antipsychotic medications, for 3 of 5 residents reviewed. The deficiency involved Resident 8, Resident 5, and Resident 99, whose records showed antipsychotic or psychotropic medication use but lacked timely documentation of Abnormal Involuntary Movement Scale (AIMS) assessments as required by the facility’s monitoring process. Resident 8 had diagnoses including bipolar disorder and moderate cognitive impairment and received Rexulti for bipolar disorder. The record showed an AIMS completed on 8/8/25, but there was no documentation that an AIMS had been completed earlier after the resident’s admission or with subsequent medication changes. Resident 5 had diagnoses including depression, dementia, and diabetes and was ordered amitriptyline for depression; the record showed an AIMS completed on 8/8/25, but no documentation of an AIMS assessment before that date. Resident 99 had diagnoses including depression and dementia and was ordered quetiapine for dementia; the record showed an AIMS completed on 2/12/25, but there was no documentation of an AIMS assessment after the most recent admission. During interview, the Regional Clinical Consultant stated that AIMS should have been completed for residents on antipsychotic medications at admission, with changes or new orders, and every six months. The DON also provided the facility policy titled Monitoring for Tardive Dyskinesia, which stated residents receiving psychotropic medications would be monitored on an ongoing basis at regular intervals and with any change in condition or medication.
Pharmacy Review and Physician Notification Deficiencies
Penalty
Summary
The facility failed to ensure a licensed pharmacist completed monthly drug regimen review of resident medications and failed to ensure physician notification of pharmacy recommendations for Resident 5. Resident 5 was admitted with diagnoses including depression, dementia, and diabetes. On review of the medical record, a pharmacy recommendation dated 5/12/25 suggested a magnesium level for medication monitoring, but the record lacked documentation that the magnesium level lab was completed or that the physician was notified. During interview, the DON stated the magnesium lab recommendation had not been completed. The record also showed physician orders dated 12/13/24 and 4/17/25 for amitriptyline 100 mg orally for depression. A mental health provider recommendation dated 5/15/25 indicated to consider a trial GDR of amitriptyline to 75 mg every evening, but the medical record lacked documentation of physician notification regarding that recommendation. The facility policy titled Medication Monitoring, Medication Regimen and Reporting stated the consultant pharmacist reviews each resident’s medication regimen and medical chart at least monthly and that recommendations should be acted upon within 30 calendar days or per facility protocols.
Medication Error Rate Exceeded During Observed Pass
Penalty
Summary
The facility failed to ensure it was free of a medication error rate greater than 5 percent during a medication pass observation. Surveyors observed 27 opportunities for error and identified 3 medication errors, resulting in an 11.1 percent medication error rate. The deficiency involved 3 of 6 residents observed: Resident 26, Resident 3, and Resident 152. For Resident 26, RN 7 administered propranolol 10 mg, but the resident's order had been changed from propranolol 20 mg twice daily to propranolol 10 mg, 2 tablets twice daily for coronary artery disease. For Resident 3, RN 15 checked an accu check of 254 mg/dL and administered 6 units of insulin lispro by insulin pen without priming the pen, and the resident did not receive lunch until 40 minutes later. For Resident 152, RN 15 checked an accu check of 196 and administered 8 units of insulin lispro by insulin pen without priming the pen, and lunch was served 22 minutes later. The Regional Clinical Consultant stated meals should have been served within 15 minutes of rapid-acting insulin administration and that the insulin lispro pen was required to be primed before each use. The consultant also provided the facility's insulin lispro instructions, which stated to prime the pen before each injection and that failure to prime may result in too much or too little insulin.
Infection Control Lapses During Glucose Monitoring and Foley Tubing Contact With Floor
Penalty
Summary
Infection control practices were not maintained during direct patient care for three residents during blood glucose monitoring. One RN washed her hands, turned off the faucet with a bare hand, dried her hands, donned gloves, and then picked up a glucometer from a resident’s dresser. She placed the glucometer on one resident’s bed and later on another resident’s bed without using a barrier, and she stated she did not sanitize the glucometer between residents and usually used alcohol wipes rather than the bleach wipes the DON said were required. The DON also stated the staff had been educated before regarding glucometers and infection control. For another resident’s accu check, an RN placed the glucometer and supplies on a barrier on the bedside table, used gloved hands to clean the resident’s fingertip, then touched a communal container of strips with the same gloves without changing gloves or performing hand hygiene. After the accu check, the RN returned the glucometer strips to the medication cart without cleaning the device. The Regional Nurse Consultant stated staff should not have touched the glucometer strip container with the same gloves used on the resident. Facility policies provided during the investigation stated the meter should be cleaned and disinfected between each patient and that licensed staff should follow manufacturer guidelines for cleaning and disinfection. The facility also failed to keep a Foley catheter tubing off the floor for a resident with severe cognitive impairment and an indwelling catheter. During multiple observations, the resident’s catheter tubing was seen in contact with the floor mat next to the bed and later in contact with the floor underneath the bed. The resident’s record showed diagnoses including neuromuscular dysfunction of the bladder and urinary retention, and orders were in place for a Foley catheter, catheter care every shift, and urinary output every shift. Staff interviewed stated the catheter tubing should not touch the floor, floor mat, or any other surface, and the Regional Clinical Consultant confirmed the tubing should not touch the floor.
Failure to Use Gloves During Food Preparation
Penalty
Summary
A dietary staff member was observed preparing peanut butter and jelly sandwiches without wearing gloves, handling sandwich bread with bare hands while spreading peanut butter. This occurred during an initial kitchen tour, with the staff member acknowledging that gloves should have been worn and that food should not be touched with bare hands. The Dietary Manager intervened, instructing the staff member to perform hand hygiene before donning gloves. The sandwiches being prepared at the time were intended for approximately ten residents for lunch and snacks throughout the day. Facility policy requires proper hand washing and glove use during food preparation, in accordance with the FDA Food Code.
Failure to Administer Scheduled Comfort Medication per Physician Order
Penalty
Summary
Facility staff failed to administer scheduled doses of comfort medication, specifically morphine, as ordered by the physician for a resident with diagnoses including dementia, COPD, atrial fibrillation, heart disease, and anxiety disorder. The physician had changed the morphine order from as-needed to scheduled every four hours to address increased pain and agitation. Despite this, Qualified Medication Aides (QMAs) did not administer several scheduled doses, documenting reasons such as the resident having no pain, being asleep, or being unable to be aroused. In some instances, the medication was withheld because the resident appeared comfortable or was unable to take the medication due to clenching teeth, and family members were present and agreed with the decision to hold the dose. The clinical record did not contain documentation of nursing assessments justifying the omission of scheduled doses, nor was there evidence that the physician was notified when doses were held. Interviews with QMAs confirmed that they made independent decisions to withhold scheduled morphine based on their observations and family input, without completing required assessments or contacting the physician. The facility's policy required that physician orders be followed and that staff notify the physician if scheduled medications were not administered, which was not done in these instances.
Failure to Implement Individualized Dementia Care Interventions Resulting in Resident Harm
Penalty
Summary
The facility failed to implement resident-specific interventions for a resident diagnosed with early onset Alzheimer's disease and anxiety disorder, who exhibited known behaviors such as intrusive wandering, verbal and physical aggression, and exit-seeking. Despite documented incidents of aggression and altercations at a previous facility, as well as multiple episodes of wandering and combative behavior upon admission, the care plans for this resident did not include individualized interventions addressing these behaviors. The care plans lacked updates to reflect the resident's history of altercations, exit-seeking, and aggressive behaviors, and did not document the implementation of increased monitoring or 15-minute checks as ordered. Observations and interviews revealed that the resident frequently wandered into other residents' rooms, including the room of another resident who later sustained significant injuries. Staff were aware of the resident's aggressive tendencies and history of entering other residents' rooms, but monitoring was inconsistent, and staff were not always positioned to observe the resident's movements. On the night of the incident, staff were occupied with care for another resident and were not able to maintain continuous observation, allowing the resident to enter another resident's room unsupervised. As a result, the resident was found leaving the room of another resident who was discovered on the floor with skin tears, scratches, and later diagnosed with a clavicle fracture and subdural hematoma. The injured resident subsequently died. Documentation and staff interviews confirmed that the facility did not have a behavior management policy available during the survey, and there was a lack of clear, individualized interventions or consistent monitoring to address the known risks associated with the resident's dementia-related behaviors.
Failure to Timely Report Suspected Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of suspected resident-to-resident abuse involving a resident who sustained significant injuries, including a non-displaced acute distal right clavicle fracture, diffuse osteopenia, and a subdural hematoma with mild midline shift, after being found on the floor in her room. The incident was initially documented as an unwitnessed fall, but multiple staff interviews and confidential concerns indicated that another resident, known for aggressive behaviors and prior resident-to-resident altercations, was seen exiting the injured resident's room immediately after the event, with fresh scratches on her arm. The injured resident, while at the hospital, repeatedly stated that a nurse had twisted her arm behind her back, causing her to fall, and also pointed to the other resident as being involved when questioned by staff. Despite these statements and observations, the facility did not immediately report the incident as suspected abuse. The facility's internal teams, including the Interdisciplinary team, Quality Assurance, and QAPI, reviewed the event and decided not to report it as resident-to-resident abuse, concluding it was a fall with injury. The incident was only reported to the state as a fall with injury after the hospital report confirmed the extent of the injuries. The facility did not attempt to contact the EMTs, hospital staff, or the family member after the resident was discharged to the hospital, and relied on a conversation with the family member, who appeared to agree it was an accident, as justification for not reporting suspected abuse. The resident who was suspected of causing the injury had a documented history of aggression, wandering, and prior altercations, both at the current facility and at a previous facility. Staff were instructed to keep the resident on 15-minute checks and to monitor her closely, but at the time of the incident, staff were occupied with other duties and did not have eyes on her. The facility's policy required all alleged violations involving abuse to be reported immediately, but no later than 2 hours after the allegation was made. However, the facility did not report the incident as abuse within this timeframe, despite multiple indicators and concerns raised by staff, family, and external parties.
Failure to Issue 30-Day Discharge Notice
Penalty
Summary
The facility failed to issue a 30-day notice of discharge prior to the planned date of a facility-initiated discharge for a resident. The resident, who was cognitively impaired and required substantial assistance with daily activities, was scheduled to be discharged to a motel without proper notification or planning. The resident's family was not issued a 30-day notice of discharge, and the resident himself was not aware of the discharge plans or his rights to appeal the decision. Interviews with staff revealed a lack of communication and coordination regarding the resident's discharge. The Social Services Director (SSD) was not aware of the resident's payor issues until it was time for discharge, and there was no documentation of discussions with the resident or family about discharge planning or alternative options. The resident's family expressed concerns about the safety of discharging the resident to a motel, given his inability to care for himself, but these concerns were not adequately addressed by the facility. The facility's records lacked documentation of a 30-day notice of discharge, and there was no evidence that the resident or his family were informed of their right to appeal the Medicare Advantage plan's decision to cut the resident's skilled stay. The facility's policy required a 30-day notice of discharge, but this was not followed, leading to confusion and potential risk for the resident.
Inadequate Discharge Planning for Resident with Complex Needs
Penalty
Summary
The facility failed to adequately plan and ensure a safe and orderly discharge for a resident with significant clinical needs, including catheter care, oxygen use, and wound care. The resident, who was cognitively impaired and required substantial assistance with activities of daily living, was scheduled for discharge without a clear plan for his care post-discharge. Interviews with staff revealed a lack of communication and coordination regarding the resident's discharge, with the Qualified Medication Aide and Certified Nurse Aides unaware of the discharge details or the resident's ability to care for himself. The Social Services Director (SSD) was not involved in addressing the resident's payor issues until the discharge was imminent, and there was no documentation of discussions with the resident or family about alternative payor options or safe discharge plans. The SSD also failed to provide necessary education to the resident and family about the resident's clinical needs and how to manage them post-discharge. The resident's family expressed concerns about the safety of discharging the resident to a motel, given his inability to care for himself, but these concerns were not adequately addressed by the facility. The facility's discharge planning process was not followed, as there was no evidence of interdisciplinary team involvement or regular re-evaluation of the resident's discharge plan. The resident's record lacked documentation of medical equipment arrangements or education provided for discharge, and the SSD did not ensure that the resident's clinical needs were addressed as part of the discharge process. The facility's failure to plan for a safe discharge resulted in confusion and potential risk to the resident's health and safety.
Verbal Abuse Incident Involving Agency LPN and Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse when a Licensed Practical Nurse (LPN) engaged in inappropriate verbal exchanges with a resident. The incident involved a resident with a history of mental health issues, including schizoaffective disorder, bipolar disorder, dementia, and anxiety disorder. The resident, identified as having moderate cognitive impairment, was known to exhibit behaviors such as screaming, cursing, and making repetitive statements. On the night of the incident, the resident was experiencing behavioral issues and approached the nurse's station, where the exchange occurred. The incident began when the resident, who was having a difficult night, approached the nurse's station and requested medication and a cigarette. The LPN, who was an agency nurse, responded inappropriately by engaging in a verbal altercation with the resident. The resident called the LPN a derogatory name, and the LPN retaliated by using the same derogatory term and further antagonized the resident with racially charged language. This exchange was witnessed by two Certified Nursing Aides (CNAs) who reported being shocked by the LPN's behavior. The facility's response included immediate actions to ensure the resident's safety, such as separating the resident from the LPN and notifying the appropriate staff members, including the Administrator and Director of Nursing (DON). The LPN was suspended and removed from the facility. Witness statements and interviews confirmed the inappropriate conduct of the LPN, and the incident was documented in the facility's records. The facility's policy on abuse, neglect, and misappropriation of property was referenced, highlighting the organization's intention to prevent occurrences of abuse, including verbal abuse.
Failure to Accurately Report Verbal Abuse Incident
Penalty
Summary
The facility failed to accurately report an incident of verbal abuse involving a nurse and a resident to the Indiana Department of Health (IDOH). The incident occurred when a Licensed Practical Nurse (LPN) and a resident, who has a history of mental health issues including schizoaffective disorder and bipolar disorder, exchanged inappropriate remarks. The resident called the nurse a derogatory term, and the nurse responded with similar language, escalating the situation. Witness statements from staff confirmed the use of foul language by the nurse towards the resident. Although the incident was initially reported to IDOH, the final report inaccurately stated that the allegation was unsubstantiated. The investigation summary and staff interviews indicated that the verbal abuse allegation was substantiated, contradicting the final report submitted to IDOH. The Assistant Administrator and Clinical Support Nurse acknowledged the error in the final report, which was submitted without completing the investigation. The facility's policy on abuse, neglect, and misappropriation of property mandates immediate reporting and investigation of such incidents, but this protocol was not followed accurately in this case. This deficiency relates to complaints IN00454858 and IN00454449.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to ensure that the Notice of Transfer/Discharge forms were completed and provided to residents and/or their representatives for four residents who were hospitalized. Resident 18, diagnosed with Alzheimer's disease, was discharged to an inpatient psychiatric hospital without the necessary documentation of the Notice of Transfer/Discharge forms. The Administrator confirmed that no such forms were found, indicating a lapse in the facility's protocol. Resident 165, who had a complete traumatic amputation of the left lower leg, was transferred to an acute care hospital and subsequently expired there. The record lacked documentation of the Notice of Transfer/Discharge forms, and the State Signature Care Consultant confirmed the absence of these forms, highlighting a failure in the facility's process for hospital transfers. Resident 138, with diagnoses including encephalopathy and malignant neoplasm, was transferred to the hospital multiple times without the completion of the required forms. Similarly, Resident 54, who had acute and chronic respiratory failure, was transferred to the hospital without the necessary documentation. The Signature Clinical Consultant acknowledged a system failure and the need for a new process to ensure compliance with transfer documentation requirements.
Failure to Complete Bed Hold Forms for Hospitalized Residents
Penalty
Summary
The facility failed to ensure that bed hold forms were completed and provided to residents or their representatives in cases of hospitalization or therapeutic leave. This deficiency was identified for three out of four residents reviewed. Resident 18, who had Alzheimer's disease, was hospitalized for a urinary tract infection and increased altered mental status, but there was no documentation of a bed hold form being completed or provided. The facility administrator confirmed the absence of the form during an interview. Resident 165, who had a complete traumatic amputation of the left lower leg, was discharged to an acute care hospital and later expired there. The hospital transfer document lacked documentation of a bed hold form, and the State Signature Care Consultant confirmed the absence of the form during an interview. Similarly, Resident 138, who had multiple hospital transfers due to conditions such as encephalopathy and heart failure, also lacked documentation of bed hold forms for her transfers. The facility administrator acknowledged the missing documentation during an interview. Additionally, Resident 54, who had been hospitalized recently, also lacked documentation of a bed hold form for their transfer. The Signature Clinical Consultant identified a system failure in completing these forms and acknowledged the need for a new process and staff re-education. The facility's policy required that residents and their representatives be notified of the bed hold policy at admission and during any hospital transfer, but this was not adhered to in the cases reviewed.
Failure to Notify Physician of Medication Administration Issues
Penalty
Summary
The facility failed to notify the physician of not administering medications as ordered for two residents, leading to a deficiency in medication management. Resident 76, who had multiple diagnoses including type 2 diabetes mellitus, schizophrenia, and hypertension, did not receive several prescribed medications on multiple occasions. The Electronic Medication Administration Record (EMAR) showed that medications such as Ativan, Atorvastatin, Buspirone, and others were not administered on specified dates, and there was no documentation of physician notification or resident refusal of medication. The Signature Clinical Consultant indicated that if a medication was unavailable, the nurse should contact the physician and check the emergency drug kit for alternatives. Resident 74, diagnosed with brief psychotic disorder and major depressive disorder, also experienced medication administration issues. The January 2025 Medication Administration Record (MAR) indicated that risperidone was not administered on several occasions due to unavailability, and there was no documentation of physician notification. A late entry in the physician progress note revealed that the physician was only informed of the medication unavailability during a visit on January 20, 2025, despite the medication being unavailable for several days prior. The Director of Nursing (DON) confirmed that the facility's expectation was for staff to complete a Situation, Background, Assessment, and Recommendation (SBAR) form and notify the physician when medications were not available. The lack of timely physician notification and documentation of medication administration failures for both residents highlights a significant deficiency in the facility's medication management practices.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman of resident transfers to hospitals for three residents during a specified month. Resident 18, diagnosed with Alzheimer's disease, was hospitalized and later transferred to an inpatient psychiatric hospital, but there was no documentation of Ombudsman notification. The Administrator confirmed the lack of documentation for any resident transfers during that month. Resident 165, who had a complete traumatic amputation of the left lower leg, was transferred to a hospital where they later expired. Again, there was no documentation of Ombudsman notification. Similarly, Resident 138, with diagnoses including encephalopathy and acute on chronic systolic heart failure, was transferred to a hospital multiple times without Ombudsman notification. The Signature Care Consultant confirmed the absence of documentation due to staffing changes. The facility's policy requires Ombudsman notification for all facility-initiated transfers or discharges.
Failure to Adhere to QMA Scope of Practice for Wound Care
Penalty
Summary
The facility failed to ensure that Qualified Medication Aides (QMAs) adhered to proper standards of practice for a resident with multiple medical conditions, including Alzheimer's disease, anxiety disorder, acute kidney failure, and several stage 3 pressure ulcers. The resident's care plan required specific wound care interventions, such as cleansing wounds and applying various dressings. However, the Treatment Administration Records (TARs) indicated that QMAs documented completing treatments on open wounds, which is outside their scope of practice. The documentation showed that QMAs and Certified Medication Aides (CMAs) recorded performing treatments on dates when they were not authorized to do so, as they are only permitted to treat intact skin. Interviews with QMAs confirmed that they were aware of their limitations and that they should not have performed treatments on open wounds. Despite this, the TARs reflected that treatments were signed off as completed by QMAs on multiple occasions. The facility's Signature Clinical Consultant acknowledged that QMAs must practice within their scope and follow state guidelines, which prohibit them from administering treatments on advanced skin conditions, including stage II, III, and IV pressure ulcers. The deficiency was identified through a review of the resident's records and interviews with staff, highlighting a failure to adhere to professional standards of quality care.
Failure to Prevent New Pressure Wounds in Resident
Penalty
Summary
The facility failed to prevent new pressure wounds for a resident, identified as Resident 131, who was observed multiple times without offloading heel boots while lying in bed on a low air loss mattress. Despite physician orders and recommendations from wound care services to ensure the resident's heels were offloaded and to apply heel boots, the resident was repeatedly observed without the boots, which were found in the wheelchair next to the bed. The resident's medical record lacked documentation of an updated care plan reflecting the deep tissue injuries to the bilateral feet and heels, and there was no documentation of the resident's refusal to wear heel boots or to be repositioned and turned when in bed. Resident 131 had a complex medical history, including osteomyelitis, muscle weakness, a sacral pressure ulcer, dementia, severe protein-calorie malnutrition, and functional quadriplegia. The resident was cognitively impaired and required total assistance for care needs. Despite the presence of a sacral wound upon admission and new areas on both heels, the facility did not consistently follow the physician's orders or the wound care recommendations, leading to the development of new pressure wounds. The Director of Nursing Services indicated that if a resident refused to follow the plan of care, it would typically be documented in the care plan, but such documentation was absent in this case.
Inadequate Hydration for Two Residents
Penalty
Summary
The facility failed to provide adequate hydration for two residents, leading to a deficiency in maintaining their health. Resident 131 was observed multiple times lying in bed with dry skin and mouth, indicating dehydration. On several occasions, the resident's water cup was either empty or out of reach, and there was no evidence of staff ensuring the resident had sufficient fluids. The resident's medical history included severe protein-calorie malnutrition, dementia, and functional quadriplegia, requiring total assistance for care needs. Despite physician orders to monitor fluid intake and provide supplements, the resident's hydration needs were not adequately met. Resident 109 was also found to be inadequately hydrated. Observations revealed that the resident, who was sitting in a recliner, had an empty water cup on the overbed table and could not recall when it was last filled. The resident expressed thirst, and there was no indication that staff had provided sufficient fluids. The resident's medical conditions included protein-calorie malnutrition and dementia, necessitating a mechanically altered diet and extensive assistance with care. Despite care plans and physician orders to encourage fluid intake and monitor meals, the resident's hydration needs were not sufficiently addressed. Interviews with facility staff, including a Qualified Medication Aide and a Certified Nurse Aide, indicated that water was typically provided twice per day and upon request. However, the observations and resident reports suggest that this practice was not consistently followed, leading to the deficiency. The facility's hydration policy stated that residents should be provided with sufficient fluids to maintain proper hydration, but this was not effectively implemented for the residents in question.
Failure to Maintain Sanitary Oxygen Equipment
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident, specifically in the management and storage of oxygen tubing and nasal cannula. During multiple observations, the resident's oxygen tubing was found undated, and the nasal cannula was not stored in a sanitary manner. On one occasion, the nasal cannula was observed lying inside a trash can with visible trash items, and the tubing was not dated or stored in a bag when not in use. These observations were made over several days, indicating a lack of adherence to the facility's policy on oxygen administration. The resident involved had a medical history of chronic systolic heart failure and atherosclerotic heart disease, conditions that necessitate careful management of oxygen therapy. Despite a physician's order for oxygen administration and a care plan indicating the need for oxygen as ordered, the facility's records lacked documentation of proper tubing changes after the nasal cannula was found in the trash. Interviews with facility staff confirmed that the oxygen supplies should be bagged when not in use and that the tubing should be dated when changed, which was not consistently done in this case.
Failure to Complete AIMS Assessments for Resident on Anti-Psychotic Medication
Penalty
Summary
The facility failed to ensure that AIMS (Abnormal Involuntary Movement Scale) assessments were completed for a resident who was on anti-psychotic medication. The resident, who had diagnoses including Alzheimer's disease, anxiety disorder, and acute kidney failure, was receiving Zyprexa via gastric tube. Despite the requirement for AIMS assessments every six months for residents on anti-psychotic medication, there was no documentation of such assessments being completed for the resident between October 2023 and January 2025. Interviews with the Director of Nursing (DON) revealed that the facility was behind on completing AIMS assessments for some residents, and a new process had been initiated to address this issue. The Signature Clinical Consultant (SCC) confirmed the absence of a specific policy regarding AIMS assessments but acknowledged the need for them every six months. The facility's Psychotropic Medications Policy, revised in May 2024, emphasized compliance with state and federal regulations, including regular reviews for continued need and side effects of psychotropic medications.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly dated and stored in accordance with professional guidelines, as observed in four out of five medication administration carts. During the survey, it was noted that multiple insulin vials and pens, as well as eye drops, were opened but not dated. This included medications for several residents with diabetes, such as Admelog, Basaglar, Lantus, Humalog, Trulicity, Ozempic, and Tresiba, as well as Latanoprost eye drops for a resident with glaucoma. The lack of dating on these medications is contrary to the facility's policy, which requires insulin and certain other medications to be discarded after a specific number of days once opened. The observations were made during a series of inspections with the Qualified Medication Aide (QMA) and the Director of Nursing (DNS). The DNS confirmed that insulin pens should be labeled with the date they were opened, and the facility administrator indicated adherence to manufacturer guidelines for medication use. However, the failure to date these medications suggests a lapse in following these guidelines, as confirmed by the facility's policy document provided by the Signature Clinical Consultant, which outlines the expiration periods for various medications once opened.
Failure to Complete Post-Fall Assessments for Resident
Penalty
Summary
The facility failed to ensure that post-fall assessments and vital signs were completed for 72 hours following a fall incident involving Resident P. On the date of the fall, Resident P was found on the floor next to his wheelchair, incontinent of urine, but with no injuries noted after a skin assessment. Although vital signs were taken immediately after the fall, there was no documentation of further vital signs or assessments being completed in the following days as required by a physician's order. The order specified that a 72-hour follow-up assessment, including skin assessment, vital signs, and pain assessment, should be documented every shift, but the records lacked this documentation. Resident P had a history of falls and was at moderate risk for falling, with diagnoses including paroxysmal atrial fibrillation, altered mental status, and diffuse traumatic brain injury. Despite the care plan interventions to mitigate fall risks, such as offering toileting before and after meals, the facility did not update the fall risk assessment since the resident's admission. Interviews with facility staff revealed an acknowledgment of the lack of documentation and room for improvement in nursing staff's documentation practices. The facility's policy required fall risk assessments and care plan reviews following each fall, but these were not adequately followed in this case.
Failure to Arrange Transportation for Resident's Medical Appointment
Penalty
Summary
The facility failed to assist Resident C in arranging transportation to a physician office appointment. Resident C, who was admitted with conditions including diabetes, osteomyelitis of bilateral heels, hypertension, and functional quadriplegia, required maximum assistance for daily care needs. The resident was scheduled for a physician appointment but was unable to sit up and travel, leading to a rescheduling of the appointment. However, the facility did not arrange transportation for the rescheduled appointment, resulting in the resident missing the appointment. Consequently, the resident's family requested a transfer to the hospital due to the missed appointments and the need for care. Interviews with facility staff revealed a lack of coordination and communication regarding transportation arrangements. The Regional Nurse Consultant indicated that the facility used multiple companies for transfers, but there was no evidence that transportation was arranged for the rescheduled appointment. The receptionist, who was responsible for scheduling appointments, did not recall arranging transportation for the resident. Additionally, the local ambulance service confirmed that Resident C was not scheduled for a pick-up on the rescheduled date. The facility's documentation lacked evidence of the appointment and transportation arrangements, and the Assistant Administrator acknowledged that such arrangements should be reflected in the nurses' notes.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, specifically involving two cognitively impaired residents, Resident B and Resident C. On multiple occasions, Resident B was observed inappropriately touching Resident C in common areas and private rooms. Despite staff interventions to separate the residents and place Resident B on 15-minute checks, the inappropriate behavior continued throughout the day. The Director of Nursing (DON) was informed of the incidents but did not ensure adequate measures were taken to prevent further occurrences. Staff members reported the incidents to the DON, who instructed them to separate the residents and conduct 15-minute checks on Resident B. However, the staff did not document the incidents in the residents' medical records as instructed by the DON. The facility's failure to implement effective interventions and document the incidents contributed to the ongoing inappropriate interactions between the residents. Additionally, the facility did not have care plan interventions in place for Resident B's inappropriate behavior or Resident C's safety. The facility's policy on abuse, neglect, and misappropriation of property was not followed, as the incidents were not reported immediately to the appropriate authorities. The lack of documentation and inadequate response to the incidents resulted in a deficiency, as the facility did not protect the residents' right to be free from abuse. The immediate jeopardy was identified due to the facility's failure to prevent further abuse and ensure the safety of the residents involved.
Failure to Report and Document Resident Abuse Allegations
Penalty
Summary
The facility failed to report allegations of resident abuse immediately to the Administrator and the Indiana Department of Health (IDOH) for two residents. The Director of Nursing (DON) attempted to report the incidents through the IDOH facility reported incident (FRI) system but encountered technical difficulties and was unaware of alternative reporting methods. The incidents involved Resident B allegedly touching Resident C inappropriately, which was observed by multiple staff members, including CNAs and a QMA. Despite these observations, the incidents were not documented in the residents' medical records as instructed by the DON. Resident B, diagnosed with unspecified dementia and anxiety, was observed by staff members engaging in inappropriate behavior with Resident C, who had vascular dementia and anxiety. Staff members reported seeing Resident B with his hand down Resident C's pants and later found them lying together in a bed. The DON was informed of these incidents and instructed staff to separate the residents and conduct 15-minute checks on Resident B. However, the DON also instructed staff not to document the incidents in the medical records, and no additional staff was called to monitor Resident B. The facility's policy required immediate reporting of abuse allegations to the Administrator and state agencies within two hours. Despite this, the DON did not report the incidents immediately due to technical issues with the reporting system and a lack of knowledge about alternative reporting methods. The facility's failure to report the incidents promptly and the lack of documentation in the residents' medical records contributed to the deficiency identified by the surveyors.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to adequately investigate and respond to allegations of abuse involving two residents, Resident B and Resident C. The incident began when Resident B was observed by staff members, including CNAs and QMAs, to be inappropriately touching Resident C on multiple occasions. Despite these observations, the Director of Nursing (DON) did not ensure that a thorough investigation was conducted. The DON was informed of the incidents but did not collect written statements from the staff involved, and there was a lack of documentation regarding the incidents in the residents' medical records. The DON implemented 15-minute checks for Resident B and instructed staff to keep the residents separated. However, the monitoring documentation was inconsistent and lacked details about Resident B's activities or interactions with other residents. Additionally, the facility's policy on abuse and neglect was not followed, as the investigation was not documented thoroughly, and the staff were reportedly instructed not to document the incidents in the medical records. The facility's response did not include a comprehensive care plan for Resident B's inappropriate behavior or interventions to ensure Resident C's safety. Interviews with anonymous staff members revealed that the incidents were not properly addressed, and the DON's actions were insufficient to protect Resident C from further inappropriate contact. The facility's failure to conduct a proper investigation and implement effective interventions led to a deficiency in ensuring the safety and well-being of the residents involved. The lack of documentation and failure to follow the facility's abuse policy contributed to the deficiency identified by the surveyors.
Failure to Provide Personalized Care for Resident with Schizophrenia
Penalty
Summary
The facility failed to provide personalized care and interventions for a resident diagnosed with schizophrenia and other cognitive impairments, leading to multiple resident-to-resident altercations. Resident F, who resided in a secured behavioral unit, was involved in several incidents where she made physical contact with other residents or threw objects at them. Despite these occurrences, the facility's documentation lacked evidence of interventions implemented to prevent further incidents. Resident F's clinical record and behavioral care plan did not include specific strategies to address her behaviors or prevent future altercations. The care plan mentioned general interventions such as separating residents and notifying family and physicians, but it did not detail personalized approaches to manage Resident F's specific triggers and behaviors. The facility's investigations into the incidents also lacked documentation of preventive measures. Interviews with facility staff, including a Qualified Medication Aide and the Director of Nursing, revealed that staff attempted to redirect Resident F and separate her from other residents. However, these actions were not documented as part of a comprehensive care plan. The facility's administration acknowledged that Resident F was inappropriate for the facility due to her interactions with other residents, yet there was no evidence of a tailored plan to address her needs and prevent further altercations.
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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 Terre Haute
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Care Of Deming Park | 2 mi | ★★★★★ | 4 | 2 |
| Majestic Care Of Terre Haute | 2.2 mi | ★★★★★ | 9 | 0 |
| Harrison's Crossing Health Campus | 2.3 mi | ★★★★★ | 2 | 0 |
| Southwood Healthcare Center | 4.1 mi | ★★★★★ | 24 | 2 |
| Westminster Village Health & Rehab | 4.8 mi | ★★★★★ | 1 | 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.