Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Spring Mill Meadows during CMS and state inspections, most recent first.
The facility failed to hold and document quarterly care plan meetings for two residents and failed to include PICC line and enhanced barrier precautions interventions in care plans for two other residents. One resident with HTN, depression, and hemiparesis had no documented 2025 care plan meeting, and another resident with depression, anxiety, and COPD reported not being invited to quarterly meetings; staff said a meeting occurred but was not documented. Two residents with Foley catheters and PICC lines had care plans that did not address the PICC line or enhanced barrier precautions, and the DON and MDS Coordinator could not explain the omissions.
Failure to Follow EBP and Infection Control Practices: An LPN provided gastrostomy tube care for a resident on EBP without wearing a gown, a CNA completed catheter care and then handled the resident’s call light and bed controls without removing soiled gloves or performing hand hygiene, and EBP signage was not posted for residents with Foley catheters and PICC lines. Staff and residents reported gowns were not being worn during personal care, and an unbagged bed pan was found on a bedside table next to food items.
A resident with COPD, SOB, anxiety disorder, and fluctuating cognition was observed keeping multiple respiratory inhalers at bedside and stated she self-administered them. The record showed care plans noting self-administration despite no order, a nursing note that multiple inhalers and breathing vials were found in the room with some labels different from the facility pharmacy label, and no located physician order or IDT evaluation for self-administration.
A resident who could not sign because of cognition had a NOMNC showing skilled services would end, but the signature line for the resident or representative was left blank. The ED confirmed there was no resident or representative signature to show the notice was received and understood, and the appeal rights were not documented as acknowledged.
PASARR was not updated for two residents when new diagnoses and psychotropic meds were added. One resident developed severe cognitive impairment and was later diagnosed with Alzheimer's disease and dementia, with donepezil, memantine, and sertraline changes documented after the PASARR still showed no dementia history. Another resident's PASARR did not reflect duloxetine, alprazolam changes from PRN to routine, or added bupropion, despite worsening depression/anxiety and documented suicidal ideation.
Baseline care plans were not completed within 48 hours for two residents, and one resident's plan did not include required enhanced barrier precautions for indwelling devices. One resident was admitted with a PICC line and Foley catheter, IV ABT, and multiple orders, while another resident's baseline care plan was delayed until the MDS Coordinator returned after a holiday weekend.
Failure to follow physician orders for a resident’s weekly weights and another resident’s bladder scan notifications. One resident with DM, depression, and morbid obesity was ordered weekly weights after admission, but the EHR/TAR showed only two weights were obtained instead of the ordered weekly documentation. Another resident with paraplegia, hemiplegia, and hemiparesis had an order for bladder scans q6h with MD notification for readings over 400 ml, but multiple scans were above that threshold with no documented notification in the progress notes.
A resident with edema, moderate persistent asthma, and shortness of breath was observed wearing oxygen at 4.5 L/min and later 5 L/min, but the chart had no MD order for oxygen use, delivery system, flow rate, or monitoring parameters. The care plan called for oxygen as ordered, and an RN stated she could not locate an oxygen order. The facility said it treated oxygen like a medication under its med pass policy.
A resident with dementia, major depressive disorder, and chronic pain syndrome had multiple pharmacist drug regimen review recommendations declined by the physician without a documented rationale. The record included declined recommendations related to lispro, hydroxyzine, meloxicam, and docusate, and one recommendation was signed without indicating whether it was accepted or declined. The DON stated not all physicians included a rationale when recommendations were declined, and the facility policy did not require one.
The facility failed to ensure medications and biologicals in the PACU med refrigerator were properly labeled. During observation with the DON, a liquid medication had a dried crusty substance on the bottle and label, making the label illegible, and two open bottles of tuberculin solution did not have an open date. The DON stated the bottles should have been labeled when opened and that the solution was good for 30 days.
Refrigerator Temperature Monitoring and Food Discarding Deficiency: The facility failed to monitor and document temps for a reach-in cooler and failed to discard food past its discard date. During observation, a foul odor was noted when the cooler was opened, and both thermometers inside read 54 degrees. The temp log lacked entries for multiple times, and items inside included milk, juice, prepped side salads, and butter with an expired discard date. The Kitchen Manager stated the cooler likely stopped working overnight.
A staff member failed to use a gait belt during a transfer of a resident identified as a high fall risk, resulting in the resident falling and sustaining a head abrasion and a right femur fracture. The resident required substantial assistance for transfers, and facility policy mandated gait belt use for such situations. The CNA did not follow this policy, leading to the incident and injury.
A facility failed to provide a resident with prescribed cancer medication and did not schedule necessary follow-up oncology appointments. The resident, with metastatic prostate cancer, was admitted to the facility and was supposed to continue receiving Nubeqa. However, the medication was not provided due to a lack of a prescription script, and the medical director discontinued it citing high cost without consulting the oncologist. No follow-up oncology care was scheduled for 15 months, resulting in inadequate cancer management.
The facility failed to notify physicians and adhere to medication orders for five residents, leading to deficiencies in care. Residents experienced issues such as unreported high blood sugar levels, administration of medications outside hold parameters, and missed medication doses. The DON confirmed the lack of documentation and policies for physician notification, contributing to these deficiencies.
A resident with multiple health issues was improperly transferred by staff, contrary to physical therapy recommendations, leading to an incident where the resident's legs gave out. The care plan specified the use of a mechanical lift, but the order was not properly documented, resulting in staff using an unsafe transfer method.
A facility failed to conduct a timely AIMS assessment for a resident on Risperidone, an antipsychotic, and did not educate on associated black box warnings. The resident, with multiple diagnoses including dementia, was prescribed Risperidone, but the first AIMS assessment was delayed by over a month. Additionally, no education was provided on the increased risks of death and cerebrovascular events in dementia patients taking antipsychotics.
The facility failed to ensure proper medication storage and labeling, with loose medications found in carts, unlabeled dosages, and discrepancies in narcotic counts. Staff interviews revealed a lack of adherence to procedures for medication destruction and reconciliation.
A resident with multiple health conditions was not assisted in obtaining dentures despite a dental recommendation made months earlier. Observations showed the resident eating soft foods due to being edentulous. Interviews revealed no action had been taken to follow up on the dental recommendation, contrary to the facility's policy on dental services.
The facility failed to maintain proper food storage practices in the walk-in freezer, with several items found in unsealed and wet or ice-covered boxes. The Dietary Manager and Maintenance Supervisor acknowledged issues with condensation and improper defrosting methods. A resident reported that the chicken tasted as if it had been refrozen, indicating potential mishandling. The facility's policy requires frozen foods to remain solid and tightly wrapped, which was not followed.
A resident with severe cognitive impairment was incorrectly transferred to her previous home address instead of an assisted living facility due to a human error in providing the wrong address to the transport company. The resident was left in a driveway, and her son had to retrieve her after being notified by a neighbor. The facility confirmed the mistake was due to using the wrong address from the resident's face sheet.
Care plan meetings not held or documented and care plans missing device-related interventions
Penalty
Summary
The facility failed to ensure quarterly care plan meetings were held and that residents and their representatives were invited to participate for Resident 40 and Resident 57. Resident 40, whose diagnoses included hypertension, major depressive disorder, and hemiparesis/hemiplegia following cerebrovascular disease, stated he had not been to a care plan meeting, and the clinical record contained no documentation of a care plan meeting in 2025. Social Service Worker 6 stated care plan meetings were supposed to occur every 90 days and identified the last care meeting for Resident 40 as 12/26/24. Resident 57, who had major depressive disorder, anxiety disorder, and COPD, stated she had not been invited to quarterly care planning meetings. The record showed no documentation of a care plan meeting from 7/2/24 to 3/27/25, and although a progress note indicated a meeting was to be scheduled for 4/2/25, the documented meeting was not found in the record. Social Service Worker 7 stated the meeting had not been completed in the record and that she had conducted a care plan meeting in April without taking notes or documenting it. The facility also failed to develop comprehensive care plans for Resident 5 and Resident 2 related to PICC lines and enhanced barrier precautions. Resident 5 was observed with a Foley catheter and PICC line; his diagnoses included necrotizing fasciitis, obstructive and reflux uropathy, and urinary retention. Although records showed IV antibiotics had been discontinued and a nursing note documented the PICC line was in place without signs of infection, the comprehensive care plan had not been updated beyond the baseline plan and did not include the PICC line or enhanced barrier precautions for the Foley catheter. Resident 2 was observed with a Foley catheter drainage bag attached to the bed frame and a PICC line in the right upper arm; his diagnoses included obstructive and reflux uropathy, urethral discharge, and pain. His care plan, last revised 7/24/25, addressed the indwelling urinary catheter related to obstructive uropathy but did not include enhanced barrier precautions required for residents with an indwelling device. The DON stated she was not sure why these items were missing, and the MDS Coordinator stated the PICC line had been discontinued from Resident 5's care plan because antibiotic treatment had ended and that there must have been a communication error.
Failure to Follow EBP, Hand Hygiene, Signage, and Bedpan Storage Requirements
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) and infection control practices were followed during resident care, including the use of PPE, posting of EBP signage, and proper storage of a bed pan. During observation of care for a resident with a gastrostomy tube, hemiplegia, and dysphagia, an LPN performed hand hygiene and donned clean gloves but did not wear a gown while flushing the tube, administering gabapentin, and reconnecting the nutrition line. The LPN later stated that EBP required a gown and that she did not use one. During catheter care for another resident, a CNA used the appropriate enhanced barriers while cleaning the catheter line, but after completing the care she handled the resident’s call light and used the bed controls without removing her soiled gloves or performing hand hygiene. The Infection Preventionist stated the CNA should not have handled the call light with the gloves used for catheter care. The resident had diagnoses including muscle weakness, cognitive communication deficit, and difficulty walking. EBP signage was also not observed outside or inside the rooms of two residents who had Foley catheters and PICC lines, and staff and residents reported that gowns were not being worn during personal care. One resident’s record did not include EBP in the care plan, and a physician order for EBP could not be found. In addition, an unbagged bed pan was observed sitting on a resident’s bedside table next to a box of cookies, and the resident stated it had been used the night before. The DON stated the resident had been admitted with a Foley catheter and PICC line and required EBP, and the facility policy stated bedside personal equipment such as a bedpan should be maintained in a sanitary condition and stored to prevent cross contamination.
Failure to Assess and Order Self-Administration of Respiratory Medications
Penalty
Summary
The facility failed to ensure the interdisciplinary team determined that Resident 57 was safe to self-administer medications and failed to obtain a physician's order for self-administration. Resident 57 had diagnoses including chronic obstructive pulmonary disease, shortness of breath, and anxiety disorder. During observations, the resident had respiratory inhalers at bedside and stated she kept them within arm's reach and self-administered them, with nurses bringing replacements when empty. The clinical record showed care plans indicating the resident self-administered medications despite having no order to do so, and later noted that she chose to self-administer medications and preferred the nurse to leave medication at the bedside table. The record also showed that Resident 57 had cognitive impairment with cognition shifting between intact and moderately impaired. A nursing progress note documented that multiple inhalers and breathing treatment vials were found in the resident's room, including medications with labels different from the facility's pharmacy label. Physician's orders were present for Spiriva Respimat and Breo Ellipta, but no physician's order was located for the Albuterol inhaler or for self-administration of medications. An IDT evaluation addressing the resident's physical capacity, cognitive status, ability to follow directions, understanding of medication instructions, and ability to store medications safely and securely was not located in the medical record.
Missing Signature on NOMNC
Penalty
Summary
The facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) was signed by the resident or the resident's representative for Resident 68. Review of the beneficiary notices showed that skilled services were scheduled to end on 6/16/25, and the NOMNC signature section was dated 6/13/25, but the signature line for the patient or representative was blank. The form noted that Resident 68 was unable to sign because of cognition, and there was no documentation showing that anyone signed on the resident's behalf to indicate receipt and understanding of the notice or the right to appeal through the QIO. During interviews, the Executive Director stated the resident could not sign due to cognition and confirmed the NOMNC was not signed by the resident or representative.
PASARR Not Updated for New Diagnoses and Psychotropic Med Changes
Penalty
Summary
The facility failed to ensure PASARR updates were completed when new diagnoses and psychotropic medications were added for 2 residents reviewed. For one resident, the PASARR level I screen indicated no dementia or neurocognitive disorder and stated that if changes occurred, a new screen had to be submitted. After that screen, the resident was documented with severe cognitive impairment, a diagnosis of late onset Alzheimer's disease and moderate dementia with mood disturbance, and was started on donepezil and later memantine. The record also showed an increase in sertraline, a significant change in status assessment noting a new diagnosis of Alzheimer's disease, and later notes referencing that the PASARR still showed no history of dementia while the current diagnosis list included Alzheimer's disease and dementia. For the second resident, the PASARR level I indicated no current psychotropic medications and stated that if changes occurred or new information refuted the findings, a new screen had to be submitted. After admission, the resident was ordered duloxetine and alprazolam, then alprazolam was changed from as needed to routine three times daily, and bupropion was added. The resident also had worsening depression and anxiety, and a social services note documented suicidal ideation with thoughts of harming herself and a plan of action. Social services staff stated they believed the admission PASARR was accurate and that all admission medications should have been on the PASARR or a new one completed immediately, but the PASARR was not updated for the added diagnoses and medication changes.
Baseline care plans were not completed within 48 hours and lacked required EBP
Penalty
Summary
The facility failed to ensure baseline care plans were developed within 48 hours of admission and that they included enhanced barrier precautions for 2 of 4 residents reviewed. One resident was admitted by ambulance with a PICC line in the right upper extremity and a Foley catheter in place. The clinical record showed diagnoses including necrotizing fasciitis, obstructive and reflux uropathy, and urinary retention, and physician orders directed daily monitoring of the PICC site and noted the Foley catheter. The baseline care plan history reflected infection, IV antibiotic therapy, and assistance with ADLs, but it did not include enhanced barrier precautions for the resident's indwelling devices. A second resident was admitted from the hospital and had diagnoses including anemia, anxiety disorder, major depressive disorder without psychotic features, COPD, emphysema, insomnia, weakness, adult failure to thrive, age-related osteoporosis, and pain. A physician's order was entered on admission for duloxetine 60 mg daily, but the baseline care plan was not started until several days later. Staff interviews indicated the baseline care plan should have been completed within 48 hours, and that it was typically created by the MDS Coordinator; because the resident was admitted after the MDS Coordinator had left for a 3-day holiday weekend, the care plan was not completed until the MDS Coordinator returned.
Failure to Follow Orders for Weights and Bladder Scan Notifications
Penalty
Summary
The facility failed to follow physician’s orders for weekly weights after admission for a resident with type 2 diabetes mellitus, depression, and morbid obesity due to excess calories. The resident stated he did not eat every meal and believed he had lost weight, but was unsure how much. The record showed a physician’s order from 6/24/25 through 7/22/25 directing weekly weights for 4 weeks, and the care plan identified nutritional concerns including weight fluctuations related to diuretic therapy with a goal to maintain current weight without significant changes in 30 days. However, the documented weights in the EHR showed the resident had only been weighed twice since admission, and the TAR did not contain the ordered weekly weights for the 4-week period. The facility also failed to notify the physician when bladder scans for another resident repeatedly exceeded the ordered threshold. That resident had diagnoses including complete paraplegia, hemiplegia, and hemiparesis, and had a physician’s order starting 5/16/25 for bladder scans every 6 hours on each shift with notification to the physician if the scan was greater than 400 ml. The TAR showed multiple scans above 400 ml, including readings of 600 ml, 500 ml, and 451 ml on several dates, with no documented physician notification. RN 16 stated notification would be documented in progress notes, while the DON was unsure about the order and later stated it should have been discontinued after 72 hours.
Lack of Physician Order for Oxygen Use
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident 16, who had diagnoses including edema, moderate persistent asthma, and shortness of breath. On observation, the resident was wearing oxygen set at 4.5 L/min and later at 5 L/min, but the clinical record contained no physician's order for oxygen use, including the type of delivery system, when to administer it, prescribed flow rates, or when to monitor SpO2 levels and vital signs. The care plan, dated 6/19/25, identified a potential for impaired gas exchange related to asthma and included administering oxygen as ordered. During interview, an RN stated she could not locate an oxygen order and that there should be one. The Clinical Support Nurse stated the facility used the medication administration policy for oxygen orders and treated oxygen like a medication.
Physician Did Not Document Rationale for Declined Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure the attending physician documented the rationale for declining pharmacist recommendations in the monthly drug regimen review for one resident. Resident 57 had diagnoses including dementia, major depressive disorder, and chronic pain syndrome. The resident’s clinical record showed multiple pharmacist recommendations that were declined by the physician without a documented rationale, including recommendations to discontinue lispro sliding scale and relax the A1C range, to attempt a gradual dose reduction and then discontinue hydroxyzine, to discontinue meloxicam and start acetaminophen, and to discontinue docusate or replace it with Miralax if a routine laxative was needed. The record also showed recommendations that were either signed without indicating acceptance or decline, or were declined without explanation. One hydroxyzine recommendation dated 10/30/24 was missing the section of the document with the physician’s signature, and a later hydroxyzine recommendation was signed but did not indicate whether it was accepted or declined. The DON stated during interview that not all facility physicians included a rationale when drug regimen review recommendations were declined. The facility’s policy on Medication Regimen Reviews and Pharmacy Recommendations, last revised in 10/2018, did not include a requirement for physicians to provide a rationale when declining a pharmacist recommendation.
Unlabeled Tuberculin and Illegible Medication Label in PACU Refrigerator
Penalty
Summary
The facility failed to ensure that drugs and biologicals in the PACU medication storage refrigerator were labeled in accordance with accepted professional principles. During observation with the DON, the refrigerator contained a liquid medication with a dried crusty substance on the bottle and label, and the label was not legible. The refrigerator also contained two open bottles of tuberculin solution that did not have an open date. During interview, the DON stated the bottles should have been labeled when opened and that the solution was good for 30 days. The facility policy titled Medication Storage and Expiration Policy, dated 11/24, stated staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened and should destroy and reorder medications with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels or cautionary instructions.
Refrigerator Temperature Monitoring and Food Discarding Deficiency
Penalty
Summary
The facility failed to ensure refrigerator temperatures were monitored and documented to maintain proper temperatures and to discard food before the expiration date in 1 of 2 refrigerators reviewed for food storage, the reach-in cooler. During observation on 7/30/25 at 9:55 a.m., a foul odor was noted inside the reach-in cooler when the door was opened, and two thermometers inside the cooler both read 54 degrees. A second observation at 9:59 a.m. again showed both thermometers reading 54 degrees. The temperature monitoring document for the reach-in cooler, titled Equipment Temperature Monitoring, lacked recorded temperatures on 7/29/25 and 7/30/25. It showed a documented time of 2:00 p.m. but did not include the temperature inside the cooler, and it was also missing a time and temperature entry on 7/30/25. Items observed inside the cooler included milk, juice, prepped side salads, and a stick of butter with a discard date of 7/27/25. During interview, the Kitchen Manager stated the cooler must have stopped working sometime during the night of 7/29/25 because the temperature had been normal during the previous shift.
Failure to Use Gait Belt During Transfer Results in Resident Fall and Injury
Penalty
Summary
A staff member failed to follow facility policy and procedure regarding the use of a gait belt during a resident transfer, resulting in a fall. The incident involved a resident who was identified as a high fall risk, with diagnoses including muscle weakness, chronic respiratory failure, and chronic kidney disease with heart failure. The resident required substantial to maximal assistance for transfers and was cognitively intact. During the transfer from bed to wheelchair, the CNA did not use a gait belt as required by facility policy and instead held the resident by her pants, leading to the resident falling backward and sustaining injuries. The resident's family member witnessed the aftermath of the fall, finding the resident on the floor with blood coming from her head. The clinical record and hospital documentation confirmed that the resident suffered an abrasion to the forehead and a nondisplaced intertrochanteric fracture of the right femur, which required emergency surgery. The CNA involved acknowledged not using a gait belt and reported that care sheets were unavailable at the time of the incident. Multiple staff interviews confirmed that the use of gait belts was standard practice for all transfers unless a mechanical lift was used. Facility documentation showed that the CNA had completed training on gait belt use and that the facility's policies clearly required gait belts for all non-independent transfers. The failure to use a gait belt during the transfer directly led to the resident's fall and subsequent injury.
Failure to Provide Cancer Treatment and Follow-Up Care
Penalty
Summary
The facility failed to ensure that a resident received the prescribed medication for cancer treatment and did not schedule follow-up appointments with an oncologist. The resident, who had metastatic prostate cancer, was admitted to the facility in October 2023. Upon admission, the resident was supposed to continue receiving Nubeqa, a hormone therapy medication, as part of his cancer treatment. However, the medication was not provided due to a lack of a prescription script, and the facility's medical director later discontinued the medication citing its high cost, without consulting the resident's oncologist. The resident's clinical records indicated that there was no follow-up oncology care scheduled until January 2025, which was 15 months after the resident's admission to the facility. During this period, the resident did not receive the necessary cancer treatment, and there was no documentation of any consultation with the oncologist. The facility's Director of Nursing was unaware of the oncology referral appointment that was supposed to be scheduled following the resident's discharge from the hospital. The deficiency resulted in the resident not receiving appropriate cancer treatment and follow-up care, which was crucial for managing his metastatic prostate cancer. The facility's policy required verification of physician orders and pharmacy notification upon admission, but these procedures were not adequately followed. The medical director responsible for discontinuing the medication was no longer employed at the facility, and the facility was unable to obtain further information regarding the decision to discontinue the cancer medication.
Failure to Adhere to Physician Orders and Notify Physicians
Penalty
Summary
The facility failed to ensure proper notification and adherence to physician's orders for five residents, leading to deficiencies in quality of care. Resident J, diagnosed with type 2 diabetes mellitus, chronic kidney disease, and dementia, had blood sugar levels recorded above the physician-ordered parameters on multiple occasions without documentation of physician notification. The Director of Nursing (DON) confirmed the lack of documentation for notifying the physician when blood sugar levels were outside the ordered parameters. Resident H, with chronic systolic congestive heart failure, received Hydralazine despite systolic blood pressure readings below the ordered hold parameter. The Medication Administration Record (MAR) showed that the medication was administered on several occasions when it should have been held. Similarly, Resident K, with acute systolic heart failure and other conditions, was given Metoprolol and Furosemide when systolic blood pressure readings were below the hold parameters. The DON acknowledged the administration of medications outside the ordered parameters and noted the absence of a policy on holding medications. Resident B reported missing several medication doses, which was confirmed by the MAR. The missed medications included inhalers, antibiotics, and mouthwash, with no documentation of physician notification. Resident 37, with a history of hypertension and heart failure, had systolic blood pressure readings above the physician-ordered notification parameters without evidence of physician notification. The DON indicated that these readings were considered normal for the resident and were placed on a non-urgent list for the physician. The facility lacked a policy for physician notification, contributing to these deficiencies.
Failure to Follow PT Transfer Recommendations
Penalty
Summary
The facility failed to ensure that the physical therapy recommended method for transferring a resident was followed, leading to an incident involving Resident E. The resident, who had diagnoses including morbid obesity, anemia, weakness, and was receiving surgical aftercare, was being transferred by two staff members from her bed to her wheelchair when her legs gave out, and she was lowered to the floor. The physical therapy evaluation had recommended the use of a Hoyer or sit-to-stand lift for transfers due to medical reasons and safety concerns, but this recommendation was not followed during the transfer. The care plan for Resident E indicated the need for assistance with activities of daily living, including transfers, and specified the use of a sit-to-stand lift. However, there was no physician's order for a Hoyer lift or sit-to-stand lift found in the clinical record. The Director of Therapy noted that the nursing staff had failed to keep the order for the use of a Hoyer lift open-ended, leading to its immediate discontinuation. Additionally, the sit-to-stand lift was added to the care plan by word of mouth rather than through proper documentation, resulting in the staff attempting an under-the-arm transfer, contrary to the physical therapy recommendations.
Failure to Conduct Timely AIMS Assessment and Educate on Antipsychotic Risks
Penalty
Summary
The facility failed to conduct an Abnormal Involuntary Movement Scale (AIMS) assessment on a resident who was prescribed an antipsychotic medication, Risperidone, for over a month. The resident, who had diagnoses including generalized anxiety disorder, major depressive disorder, dementia, unspecified psychosis, altered mental status, and insomnia, was started on Risperidone with physician's orders dated 7/5/24. The care plan indicated that an AIMS assessment should be completed twice a year, but the first assessment was not conducted until 8/27/24, more than a month after the medication was initiated. This delay in assessment was confirmed by the Director of Nursing (DON) during an interview. Additionally, the facility did not provide education on the black box warnings associated with the use of antipsychotic medications in patients with dementia. Interviews with the DON and the Executive Director (ED) revealed that there was no education provided regarding the increased risk of death and cerebrovascular events in dementia patients taking antipsychotics, as highlighted by a study from the National Institute of Health (NIH). The facility's policy on psychotropic management, which was last reviewed in October 2022, required an AIMS assessment within 72 hours of initiating or increasing antipsychotic medication, but this was not adhered to in the case of the resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling practices across three medication carts. During observations, loose medications were found in the drawers of medication carts 1 and 3, including various pills and capsules. Additionally, a card of Tramadol for a resident was found with white tape holding a tablet in place, indicating improper handling. Medication cart 4 contained dosages of hydralazine and sodium chloride without pharmacy labels, and an inhaler with a handwritten name instead of a proper label. These findings suggest a lack of adherence to labeling and storage protocols. Furthermore, discrepancies were noted in the narcotic count logs. For instance, a narcotic reconciliation on medication cart 3 revealed an inconsistency in the Tramadol count for a resident, where the log indicated one less tablet than was present. This discrepancy was acknowledged by an LPN, who admitted the dose was not given despite being signed out. Interviews with staff, including LPNs and the Director of Nursing, highlighted a lack of clarity and adherence to the facility's procedures for medication destruction and reconciliation, contributing to the deficiencies observed.
Failure to Assist Resident in Obtaining Dentures
Penalty
Summary
The facility failed to assist a resident, identified as Resident 20, in obtaining dentures as recommended during a dental examination. Observations on two separate occasions revealed that the resident was eating soft foods and was edentulous, indicating the absence of teeth. The resident's clinical record showed multiple diagnoses, including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, bipolar disorder, schizophrenia, dementia with agitation, dysphagia oral phase, and mild intellectual disabilities. A dental examination conducted in February recommended that the resident, who expressed a desire for dentures, was a good candidate for complete upper and lower dentures, and impressions should be obtained. Despite this recommendation, a social services note from February indicated no new recommendations were made, and a care plan revised in June still noted the resident's edentulous status without dentures. Interviews with the resident and the Social Services Assistant in August confirmed that no further action had been taken to obtain dentures since the initial recommendation. The facility's policy on dental services, which mandates obtaining needed dental services and making prompt referrals, was not adhered to in this case, leading to the deficiency.
Improper Food Storage Practices in Walk-in Freezer
Penalty
Summary
The facility failed to ensure proper food safety practices in the walk-in freezer, as observed during a kitchen inspection. Several food items, including garlic toast, pork sausage links, egg omelets, egg rolls, cheese omelets, marinated diced white chicken, and diced ham, were found stored in unsealed bags and boxes that were either wet or covered in ice. The Dietary Manager acknowledged the presence of ice-covered and wet boxes, attributing it to condensation as explained by the food service delivery person. Additionally, a resident reported that the chicken tasted as if it had been frozen, thawed, and then refrozen, indicating potential mishandling of food storage. The Maintenance Supervisor admitted that moisture and condensation occurred during the stocking of supplies and described his method of defrosting the freezer, which involved shutting off the power and leaving the door open without taking measures to catch melting ice. The Administrator noted that the freezer was supposed to be auto-defrosting and should not require manual defrosting. The facility's current food storage policy, last revised in May 2024, mandates that frozen foods should remain solid, be tightly covered or wrapped, and not be refrozen after thawing, which was not adhered to in this instance.
Resident Transfer Error Due to Incorrect Address
Penalty
Summary
The facility failed to ensure a proper transfer for a resident, identified as Resident F, due to an incorrect address being provided to the transport company. Resident F, who had severe cognitive impairment and multiple medical diagnoses including malignant neoplasm of the lung and dementia, was supposed to be transferred to an assisted living facility. However, the transport company mistakenly took her to her previous home address and left her in the driveway, as the wrong address was given by the facility's Social Services Director. The incident was discovered when Resident F's son and a neighbor called the facility to report that the resident had been left at the wrong location. The neighbor attempted to alert the transport driver, but the driver left without addressing the situation. The resident's son had to leave work to pick her up, finding her in soiled clothes, which he had to change before taking her to the correct assisted living facility. Interviews with facility staff, including the Executive Director and Social Services Assistant, confirmed that a human error led to the wrong address being provided to the transport company. The facility had a contract with the transport company for resident transportation, but the address on the resident's face sheet was mistakenly used instead of the assisted living facility's address. This error was not the first instance of incorrect addresses being given to the transport company.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brickyard Healthcare - Willow Springs Care Center | 0.1 mi | ★★★★★ | 0 | 0 |
| St Augustine Home For The Aged | 0.2 mi | ★★★★★ | 0 | 0 |
| Marquette | 0.5 mi | ★★★★★ | 3 | 0 |
| Harcourt Terrace Nursing And Rehabilitation | 0.6 mi | ★★★★★ | 27 | 0 |
| Hooverwood | 2.4 mi | ★★★★★ | 12 | 1 |
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