Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Waters Of Huntingburg, The during CMS and state inspections, most recent first.
A resident with HF, A-fib/flutter, hypokalemia, and HTN had digoxin increased from 125 mcg to 250 mcg, but the facility did not document the ordered repeat digoxin level or consistent HR/BP monitoring with administration. The resident later declined with bradycardia and confusion, was sent to the hospital, and was admitted to the ICU with digoxin poisoning, hyperkalemia, and AKI; the ED recorded a digoxin level above therapeutic range and a critically elevated potassium.
A resident’s admission MDS assessment was not completed within the required 14-day timeframe. Surveyors found that the admission MDS, dated with the resident’s admission date, remained incomplete upon record review. In an interview, the DON acknowledged that the admission assessment should have been completed. Facility policy titled “Guidelines for Assessments,” provided by an RN, requires that comprehensive admission MDS assessments be completed no later than the 14th calendar day after admission, but this standard was not met, resulting in a cited deficiency.
Surveyors found that a newly admitted resident with paraplegia, chronic pain, and anxiety did not have a required baseline care plan completed and implemented within 48 hours of admission. Record review showed no baseline care plan in the chart, and the DON acknowledged it should have been completed. Facility policy, provided by an RN, requires a baseline care plan for every new admission within 48 hours to guide initial care and communication, but this was not done for this resident.
Two residents did not receive multiple doses of prescribed routine medications after admission because the medications were not available, despite existing physician orders for methadone, Lyrica, and buspirone to treat chronic pain, anxiety, and related conditions. One resident with anxiety and bipolar disorder missed several days of methadone and Lyrica, and another resident with paraplegia and chronic pain went nearly a full day without routine medications, as documented on the MARs. A nurse documented contacting the pharmacy and being told prescriptions were needed, and the DON acknowledged that late admission orders not sent to pharmacy until the evening could delay medication availability until the following evening, even though the facility’s policy requires routine and emergency pharmacy services to be available seven days a week and 24/7, respectively.
Two residents did not have their comprehensive admission MDS assessments completed within the required 14-day timeframe. Surveyors found that both residents’ admission MDS assessments were incomplete on review, despite facility policy requiring completion no later than the 14th calendar day after admission. In an interview, the MDS nurse reported being occupied with a care plan project and acknowledged not completing all due MDS assessments, and the DON provided the written policy confirming the required assessment timelines.
The facility failed to provide necessary treatment and services for two residents with dementia by not adequately monitoring, documenting, or care-planning for their behaviors, and by not maintaining a safe environment. One resident with severe cognitive impairment and psychotic symptoms had multiple aggressive episodes toward staff and other residents, including entering others’ rooms and grabbing them, yet at least one incident was not documented and the behavior care plan was not updated with new interventions. The same resident was found eating an unsecured denture cleaning tablet left in the room on a dementia unit, contrary to staff expectations that such items be stored away from resident access. Another resident with Alzheimer’s disease, anxiety, psychosis, impaired cognition, and decreased visual acuity was observed sitting on the floor in a common area while nearby CNAs did not assist her until an administrator intervened; this behavior was neither care-planned nor documented or assessed in the nurse’s notes, despite existing care plan directives to supervise, assess the environment, and intervene when inappropriate behaviors occur.
Surveyors found that physician-ordered diets were not followed for two residents. One resident with orders for fortified foods and ice cream at lunch and dinner did not receive ice cream, and staff reported that ice cream was not kept in stock and residents with such orders did not receive it. Another resident with Alzheimer’s disease and anorexia, ordered a fortified, finger food-focused diet, was served the same plated meal as others instead of finger foods, and an LPN confirmed that residents with finger food orders typically received the standard meal. The DON acknowledged there was no specific policy on following diet orders, only a general expectation to follow all physician orders.
Food Served at Unsafe and Unappetizing Temperatures: Three residents raised concerns at a resident council meeting about food taste, variety, and temperature. A meal tray tested later showed a hoagie sandwich that felt and tasted cold at 107.7 F and fries that were cold at 96.7 F, despite the facility policy stating hot foods must be held at 135 F or greater throughout the service process.
Food Temperature Logs Not Completed Before Service: Kitchen staff failed to complete food temperature logs for meals observed during tray line service. An employee stated temps were taken when food was removed from the ovens and placed on the steam table, but the log was left blank until after carts went out. The Dietary Mgr later said she had the temps in her head and would write them in later, while the RDO said staff should record temps on paper first and then enter them into the log. A facility policy stated TCS food temps shall be recorded before being served from the steam table.
Failure to Notify Physician and Family After Change in Condition: A resident with dementia and psychotic disorder fell and later developed lethargy, increased confusion, slurred speech, and difficulty walking. Nursing documented the change in condition, but no parties were notified at that time; the DON stated staff delayed notification while trying to treat the resident in-house, and the resident was later sent to the ER when symptoms worsened.
MDS assessments did not accurately reflect medication use for three residents. One resident with dementia, DM, and HTN had an MDS that showed an anticoagulant and no antiplatelet use, but the MAR showed ASA use and no anticoagulant order. Another resident with DM, dementia, anxiety, and depression had an MDS that showed an antipsychotic and no anticonvulsant use, but the MAR showed Gabapentin use and no antipsychotic order. A third resident with anxiety and a psychotic disorder had an MDS that showed no antidepressant use, but the MAR showed Mirtazapine use; the MDS Coordinator said the medication entries were in error.
Failure to follow fall-risk care plan interventions for two residents. One resident with severe cognitive impairment and extensive ADL assistance needs was left in the dining room long after lunch ended and was not toileted as planned, while another resident with dementia had a call light out of reach and no Dycem observed under common-area furniture legs despite the care plan.
Failure to update fall care plans after repeated resident falls. Three residents with severe cognitive impairment and significant assistance needs had multiple falls documented, but the clinical record did not show new falls interventions added after several events. In some cases, staff noted immediate measures such as gripper socks, a low bed, or a pressure reduction mattress, yet those interventions were not reflected in the care plan or were added later than expected. The DON stated that after a fall, an IDT meeting should occur promptly and any new interventions should be entered into the care plan the same day.
Failure to follow insulin orders and document BG monitoring: A resident with DM and dementia received the wrong Humalog dose when an RN gave 9.0 units instead of the ordered 9.5 units for a BG of 537, and the MAR was documented as if the full ordered dose had been given. Another resident with DM had multiple blank MAR entries showing missed BG checks and missed insulin doses for both Lantus and insulin lispro, with no documented reason for the omissions.
Failure to maintain hand hygiene and clean technique during med passes and incontinence care. An LPN, RN, and QMA did not sanitize hands before or after med passes, and one LPN washed hands with only a seven-second lather after giving meds. During incontinence care, a CNA touched multiple items with the same gloves, did not change gloves or perform hand hygiene between dirty and clean tasks, ran out of wipes, and left a resident with a brown substance still on the buttocks.
Failure to post current nurse staffing information: The facility's posted staffing forms were not updated in real time and did not list specific hours worked for nursing staff. On repeated observations, the evening shift was left blank, and the forms showed varying RN, LPN, CNA, and QMA entries for the day and night shifts. An LPN reported she was the only nurse on the floor during the morning, and Regional Clinical Support stated staffing forms were only updated the next day.
A resident with polyneuropathy and moderate cognitive impairment did not receive prescribed doses of Lyrica due to an incorrectly entered physician order by staff, resulting in missed and reduced doses without physician authorization. The resident experienced increased pain, and staff confirmed the medication change was not ordered by a physician.
The facility failed to provide adequate staffing on a locked dementia unit, with no licensed nurse stationed and insufficient documentation of resident behaviors. A resident with severe cognitive impairment exhibited aggressive and inappropriate behaviors that were not consistently documented, while another resident was found in another's bed without proper monitoring. The facility's staffing did not meet its own specifications, and there was no policy related to staffing.
The facility failed to monitor and document behaviors for two residents with dementia, leading to deficiencies in care. One resident exhibited inappropriate sexual behaviors without proper documentation, while another was found in another resident's bed, indicating inadequate monitoring of wandering. Despite care plans and physician orders, staff did not consistently document or address these behaviors, contrary to facility policy.
The facility failed to ensure accurate documentation of resident records for three residents, leading to discrepancies in medical records. Neuro checks were recorded by staff members who were not scheduled to work at the time, and there was no documentation to verify their presence. The facility lacked a current policy for accurate documentation.
The facility failed to notify physicians of critical changes in residents' conditions, including elevated blood sugar levels and missed medication doses. Two residents experienced high blood sugar readings without physician notification, and another resident missed doses of Cefepime for a UTI without the physician being informed. The DON acknowledged the lack of documentation and notification, which was against facility policy.
The facility failed to maintain a sanitary environment, as evidenced by missing documentation of UTIs for three residents and improper hand hygiene and glove use during incontinence care for a resident. Staff did not follow the facility's policies on infection control, leading to deficiencies in infection tracking and prevention.
The facility failed to develop and implement comprehensive care plans for two residents, resulting in unaddressed medical needs. One resident lacked care plans for multiple medications despite having physician's orders, while another resident did not have a care plan for smoking/vaping and a recommended NAS diet restriction was not implemented. The DON acknowledged the oversight and the absence of a policy to ensure prompt execution of dietary recommendations.
A facility failed to provide adequate respiratory care for a resident with COPD. The resident received oxygen without proper monitoring of oxygen saturation levels or the amount of oxygen used. The clinical record lacked a care plan for oxygen use, and staff did not correct the resident's incorrect use of the nasal cannula. The facility's policy required regular monitoring, which was not followed, leading to the deficiency.
The facility did not adhere to professional standards for food service safety, as food temperature logs lacked documentation for 12 out of 19 days. The Dietary Manager noted that newer staff might need re-education on recording food temperatures before serving, as per the facility's policy.
The facility failed to administer or document pneumococcal vaccines for three residents. One resident, severely cognitively impaired, did not receive a second dose of the vaccine. Another resident, with moderate cognitive impairment, had a signed consent but no documentation of the vaccine being offered or administered. A third resident, cognitively intact, also had a signed consent but lacked documentation of the vaccine being ordered or administered. The facility's policy required documentation of vaccine administration or refusal, which was not followed.
A resident with cellulitis and bowel incontinence did not receive care according to physician orders and care plans. The facility failed to notify the physician of changes in the resident's condition, administer treatments with proper orders, and update care plans. Stool samples were not consistently obtained, and wound assessments were incomplete, leading to inadequate care management.
A resident with chronic pressure ulcers did not receive adequate care, as the facility failed to follow care plan interventions, place necessary orders, and correctly stage pressure ulcers. Wound treatments were missed, and documentation was lacking. Skin assessments were not conducted as scheduled, and new treatment orders were not initiated. The facility also lacked a current policy for pressure ulcer prevention and treatment.
A resident with severe cognitive impairment experienced two unwitnessed falls, and the facility failed to conduct necessary neuro checks or update the care plan. Despite policies requiring these actions, staff interviews confirmed that the procedures were not followed, leading to a deficiency in supervision and fall prevention.
A resident with a UTI missed four doses of an IV antibiotic due to a failure in medication administration. The MAR showed missed doses of Cefepime, with no nurse notes or physician notification documented. The DON confirmed the lack of documentation and investigation into the missed doses, contrary to the facility's policy.
The facility failed to securely store medications as required, with a narcotic lock box found unlocked on a medication cart in the 100/200 hall. The ADON confirmed it should have been locked, and the DON provided a policy indicating Schedule II drugs must be stored under double locks.
The facility did not ensure daily updates of nurse staffing sheets, as observed on one occasion when the posted information was outdated by several days. The DON stated that the ADON was responsible for daily checks, and the night shift was to update the sheets nightly. However, the staffing information was not current, violating the BIPA Staffing Posting Requirements policy.
A resident with dementia and behavioral disturbances was given psychotropic medications beyond the 14-day limit without proper documentation or assessment. The facility failed to consistently monitor behaviors and follow physician orders, including conducting an EKG for Geodon use. Staff interviews revealed gaps in documentation and adherence to policies, leading to the deficiency.
A resident with dementia exhibited inappropriate sexual behaviors towards others in a locked dementia unit. Despite physician orders for a Climara patch to manage these behaviors, the facility staff did not administer it, and the care plan was not updated. The facility's behavior management policy was not effectively followed, leading to continued inappropriate actions by the resident.
The facility failed to provide proper foot care for five residents, resulting in long, thick, and curling toenails, as well as ingrown toenails. Residents had not seen a podiatrist due to insurance issues or lack of coordination, and clinical records lacked care plans or notes related to foot care.
The facility failed to ensure a comfortable environment for residents, staff, and the public, as evidenced by sticky floors in 11 of 29 observed rooms. The issue was attributed to the reaction of cleaning chemicals with floor wax, and there was no written plan to address it. Progress on replacing the flooring with vinyl was slow due to the workload and daily maintenance needs of the facility staff.
The facility failed to ensure proper perineal care for two residents, resulting in pain and discomfort. One resident experienced aggressive wiping with a dry washcloth, while another resident's labia was wiped inappropriately despite complaints of pain. Both incidents indicate a failure to follow care plans and facility policies.
The facility failed to follow proper infection control practices during perineal care and bed baths for three residents. Staff did not wash hands for the required duration and did not change gloves between dirty and clean tasks, contrary to the facility's hand hygiene and gloves policies.
Failure to Monitor Digoxin Therapy and Vital Signs
Penalty
Summary
The facility failed to ensure a resident's lab work and vital signs were monitored after the resident's digoxin dose was increased per physician orders and the care plan. The resident had diagnoses including heart failure, atrial fibrillation, atrial flutter, hypokalemia, and hypertension, and the most recent quarterly MDS indicated moderate cognitive impairment. Physician orders included digoxin 125 mcg for atrial fibrillation, a repeat digoxin level in two weeks, then digoxin 250 mcg for increased heart rate, along with clonidine HCl 0.2 mg as needed for systolic blood pressure greater than 180 mm Hg. The care plan included monitoring labs as ordered and monitoring blood pressure per physician order and facility policy. The MAR showed digoxin 125 mcg was given daily until 2/13/26, with heart rate documented with each administration up to that point. Digoxin 250 mcg was started on 2/14/26 and continued daily through February, March, and April, but there was no documented heart rate monitoring with administration after the dose increase. The ordered digoxin level for 2/27/26 was not documented as completed, and the resident's blood pressure was documented only on two occasions after the clonidine order was obtained from the hospital on 4/27/26. Documented vital signs included heart rates as low as 41 bpm and blood pressures including 142/100, 140/88, 145/64, 130/84, and 109/70. The resident later declined while propelling herself to the dining room and was assisted by staff as her condition worsened. A nurse documented heart rates of 38-43 bpm, inability to perform baseline ADLs, confusion about where she was, and inability to feed herself as usual, and EMS was called. Hospital records showed the resident was admitted to the ICU with digoxin poisoning, hyperkalemia, and acute kidney injury; the ED documented a digoxin level of 2.39 ng/mL and potassium of 9.4 mEq/L, with concern for chronic overdose with suspected AKI. The DON stated the resident's heart rate should be monitored prior to every digoxin administration, while another RN stated vital signs should be obtained at every medication pass but were not documented every time they were obtained.
Failure to Complete Admission MDS Assessment Within Required 14-Day Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to complete a required admission Minimum Data Set (MDS) assessment within the mandated timeframe for one resident. Record review on 3/19/26 at 11:20 A.M. showed that Resident C’s admission MDS assessment, dated with the resident’s admission date, was incomplete, despite the resident having been admitted on that same date. During an interview on 3/20/26 at 1:35 P.M., the DON stated that Resident C’s admission assessment should have been completed. The facility’s policy, “Guidelines for Assessments,” dated 5/29/24 and provided by RN 4 on 3/20/26 at 10:37 A.M., specifies that comprehensive admission MDS assessments must be completed no later than the 14th calendar day of the resident’s admission. The surveyors determined that this requirement was not met for Resident C, resulting in noncompliance with 410 IAC 16.2-3.1-31(d)(1). This citation relates to intakes 2803022 and 2799537.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Surveyors determined that the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission for one of three newly admitted residents with pressure ulcers. Record review on 3/19/26 at 11:20 A.M. showed that Resident C, whose diagnoses included paraplegia, chronic pain, and anxiety, was admitted on an identified date but had no baseline care plan in place. During an interview on 3/20/26 at 1:35 P.M., the DON stated that Resident C’s initial baseline care plan should have been completed. On 3/20/26 at 1:08 P.M., RN 4 provided the facility’s policy, dated 3/23/21, which requires that every resident have a baseline care plan completed and implemented within 48 hours of admission to promote continuity of care and communication among staff, increase resident safety, safeguard against adverse events most likely to occur after admission, and ensure the resident and representative receive a written summary of the initial plan of care. This requirement was not met for Resident C. This citation relates to intakes 2803022 and 2799537 and 410 IAC 16.2-3.1-30(a).
Failure to Provide Timely Access to Prescribed Medications After Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmaceutical services provided timely access to prescribed routine medications for two residents after admission, resulting in multiple missed doses due to medications being unavailable. One resident with diagnoses including anxiety, bipolar disorder, and panic disorder reported not receiving all prescribed medications since admission. Record review showed this resident had physician orders for methadone hydrochloride for chronic pain and Lyrica for anxiety, but the March 2026 MAR documented that methadone 10 mg (one tablet in the morning) was not administered on two dates, methadone 10 mg (three tablets in the morning) was not administered on two subsequent dates, and Lyrica 150 mg three times daily was not administered for all three doses on two consecutive days, all due to the medications being unavailable. Nursing notes indicated that on one of those days the nurse called the pharmacy about the Lyrica and methadone, and the pharmacy reported they needed prescriptions. Another resident with paraplegia, chronic pain, and anxiety reported going nearly a full day without any routine medications following admission. Record review showed this resident had physician orders for buspirone 5 mg twice daily and Lyrica 150 mg three times daily, but the February 2026 MAR documented that buspirone was not administered for one evening and the following morning dose, and Lyrica was not administered for one night dose and all three doses the following day, again due to the medications being unavailable. In an interview, the DON stated that if residents are admitted later in the day and physician orders are not sent to the pharmacy before the evening of admission, residents may not receive their medications until the following evening, and that if medications are not available, staff should obtain them from the emergency drug kit if available. The facility’s pharmacy services policy indicated that the pharmacy is to provide routine and timely pharmacy service seven days per week and emergency pharmacy service 24 hours per day, seven days per week.
Failure to Complete Admission MDS Assessments Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to complete required admission Minimum Data Set (MDS) assessments within the mandated 14-day timeframe for two residents. Record review on 1/23/26 at 10:00 A.M. showed that Resident C’s admission MDS assessment, dated with an admission date documented in the record, was incomplete beyond the required completion window. Similarly, record review on 1/23/26 at 10:40 A.M. showed that Resident D’s admission MDS assessment, also dated with an admission date documented in the record, was incomplete and not finished within 14 calendar days of admission. During an interview on 1/23/26 at 11:55 A.M., the MDS nurse stated she had been busy working on a care plan project and had not completed all due MDS assessments. The DON provided a policy titled “Guidelines for Assessments,” dated 5/29/24, which states that comprehensive admission MDS assessments must be completed no later than the 14th calendar day of the resident’s admission, confirming that the incomplete assessments for these two residents were not done timely as required. No additional clinical history or specific medical conditions for the residents were documented in the report beyond their admission status and the timing and completeness of their MDS assessments.
Failure to Monitor, Document, and Address Dementia-Related Behaviors and Environmental Safety
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services for residents with dementia, specifically related to behavior monitoring, care planning, documentation, environmental safety, and staff response. One resident with dementia, mood disturbance, and major depressive disorder with psychotic symptoms had a history of severe cognitive impairment and behavioral symptoms, including aggression toward staff and other residents. Documented incidents included lunging and swinging at staff, verbal aggression, and attempts to grab another resident. Additional facility-reported incidents described the resident making contact with another resident’s neck in a common area and entering another resident’s room and grabbing her forearm, as well as an episode where the resident was found in another resident’s room with both hands firmly gripping her wrist while yelling delusional statements. Despite these events, there was no nursing documentation in the record for at least one of the reported incidents, and the care plan, which addressed behavioral symptoms related to dementia, was not revised with new or updated interventions following the new or escalating behaviors. The same resident was also found eating a denture cleaning tablet (Polydent) after it had been left in his room on the dementia unit. Staff interviews confirmed that denture tablets and other personal hygiene items should not be left in resident rooms on a dementia unit and should instead be stored away from resident access. The incident required consultation with poison control and monitoring for adverse symptoms, but the underlying issue was that the denture tablet had been left unsecured in the room of a cognitively impaired resident. The facility’s own behavior management policy required investigation of behaviors to determine root cause and daily monitoring and documentation of target behaviors, but the record lacked documentation of at least one behavior incident and did not show that the care plan had been updated in response to the resident’s new or increased behaviors. A second resident with Alzheimer’s disease, anxiety, unspecified psychosis, impaired cognition, and decreased visual acuity was observed sitting on the floor in a common area in front of the nurse’s station while two CNAs were nearby and did not assist her until the facility administrator intervened and helped her to a couch. Staff later reported that this resident sometimes sits herself on the floor. The resident’s care plan addressed altered communication, risk for injury and/or social isolation due to decreased visual acuity, impaired cognition, and behavioral symptoms, with interventions such as assessing and modifying the environment for safety, cueing, reorienting, supervising as needed, and intervening when inappropriate behavior is observed. However, there was no specific care plan addressing the resident’s behavior of sitting on the floor, and there was no nursing documentation, observation, or assessment in the progress notes regarding this floor-sitting episode, despite staff acknowledging that a resident found on the floor should be assessed and documented and that staff should consider the reasons for such behavior.
Failure to Follow Physician-Ordered Therapeutic Diets
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-prescribed diets for two residents reviewed for dietary services. For one resident with physician orders for fortified foods with each meal and ice cream with lunch and dinner, nursing staff reported that the facility did not keep ice cream in stock and that residents with orders for ice cream did not receive it. During a mealtime observation, this resident’s lunch tray did not include ice cream, despite the active order. Staff interviews confirmed that ice cream was only available if staff purchased it themselves and that residents with ice cream orders were not provided ice cream as ordered. Another resident, diagnosed with Alzheimer’s disease and anorexia, had physician orders for fortified foods with each meal and a finger food-focused diet. During a mealtime observation, this resident received the same meal as other residents, consisting of fish, noodles, cooked vegetables, and a roll, rather than finger foods. The resident used a fork to poke at the food and took a bite, but the ordered finger food-focused diet was not provided. An LPN stated that residents with orders for finger foods usually did not receive them and instead were given the same meal as everyone else. The DON reported there was no policy specific to following diet orders, but stated it was the policy to follow all physician orders.
Food Served at Unsafe and Unappetizing Temperatures
Penalty
Summary
The facility failed to ensure residents received food at safe and appetizing temperatures for 1 of 1 meal trays tested for taste and temperature. During the resident council meeting on 9/8/25 at 10:30 A.M., three residents voiced concerns about the taste, variety, and temperatures of the food. Later that day at 12:30 P.M., a meal tray was obtained for testing, and the hoagie sandwich made with a hamburger bun, slice of cheese, and piece of ham felt and tasted cold and measured 107.7 degrees Fahrenheit. The fries were also cold to the touch and taste and measured 96.7 degrees Fahrenheit. On 9/12/25 at 10:36 A.M., the Administrator provided a current undated Food Temperatures Policy stating hot foods are to be held at 135 F or greater throughout the service process.
Food Temperature Logs Not Completed Before Service
Penalty
Summary
The facility failed to distribute and serve food in accordance with professional standards for 1 of 1 kitchen observed because food temperature logs were not completed for all meals. During an observation on 9/7/25 at 11:30 A.M., [NAME] 3 was plating chili mac, Italian vegetable blend, cornbread, and pears for the lunch meal. At 12:11 P.M., the Memory Hall cart left the kitchen, and the meal temperature log was reviewed and found to be completely blank. [NAME] 3 stated that food temperatures were taken when the food was removed from the ovens and placed on the steam table, and that temperatures would be written in the log after the last cart went out. On 9/8/25 at 12:05 P.M., the Dietary Manager was observed plating ham and cheese hoagies, baked french fries, baked beans, and lime gelatin with diced pears for lunch. The dinner log for 9/7/25 was still completely blank, and the lunch log for 9/8/25 was written in pencil and not completely filled in. The RDO was standing next to the log book with a pencil, and the Dietary Manager stated she had taken the temperatures but had not written them in the book yet and would do so later. The RDO stated she expected kitchen staff to fill out the food temperature log after the tray line was complete, using temperatures first written on paper and then transferred to the log. When copies of the log were requested, the RDO later provided a copy in which the 9/7/25 dinner log and the rest of the 9/8/25 lunch log had been filled in. A current, non dated Food Temperature Policy stated that temperatures of TCS foods shall be recorded before being served from the steam table.
Failure to Notify Physician and Family After Change in Condition
Penalty
Summary
The facility failed to ensure proper notification to the resident, the resident's physician, and a family member after a change in condition for one resident reviewed for falls. Resident 17 had diagnoses including dementia and psychotic disorder, and the most recent significant change MDS dated 8/13/25 indicated severe cognitive impairment with no behaviors. The resident required partial to moderate assistance with toileting, substantial to maximum assistance with showers, and supervision or touching assistance with eating. The current falls care plan dated 7/29/25 included an intervention to notify and update the MD as needed. After Resident 17 fell on 9/2/25 while coming through the dining room doorway, the resident hit their head and sustained an open abrasion, an abrasion to the nose, and a skin tear to the left hand. On 9/5/25, a nursing note documented that the resident was very lethargic, more confused than usual, attempting to drink food, needed assistance with lunch, and had speech that was hard to comprehend, but no parties were notified of the change in condition at that time. Twenty-six hours later, on 9/6/25, another nursing note documented that the resident was lethargic and restless, unable to walk or get up without assistance, hard to awake, and had slurred speech, after which the resident was sent to the ER for evaluation and treatment. The DON stated staff had not notified the physician after the 9/5/25 change in condition because they were trying to keep the resident in-house and treat at the facility instead of sending the resident out, and notification was made the following day when the resident seemed worse.
MDS assessments did not accurately reflect resident medication use
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to accurately reflect medication use on the MDS for 3 of 21 residents reviewed. For Resident 13, whose diagnoses included dementia, diabetes mellitus, and hypertension, the most recent significant change MDS dated 8/8/25 indicated use of an anticoagulant and no antiplatelet use, but the clinical record showed an order for Aspirin 81 mg nightly for hypertension dated 8/3/25 and discontinued 8/15/25, with the MAR showing Aspirin administration during the MDS look-back period and no anticoagulant administration documented. The record review also showed no order for an anticoagulant medication. For Resident 2, whose diagnoses included diabetes mellitus, dementia, anxiety, and depression, the most recent significant change MDS dated 8/11/25 indicated use of an antipsychotic and no anticonvulsant use, but the clinical record showed an order for Gabapentin 300 mg by mouth with meals dated 7/23/25, and the MAR showed Gabapentin administration during the look-back period with no antipsychotic documented. For Resident 6, whose diagnoses included anxiety and psychotic disorder, the most recent significant change MDS dated 8/15/25 indicated no antidepressant use, but the clinical record showed an order for Mirtazapine 7.5 mg in the evening dated 6/28/25, and the MAR showed Mirtazapine administration during the look-back period. The MDS Coordinator stated on 9/11/25 that the medications for these residents' most recent MDS assessments were entered in error, and that the facility used the RAI manual in lieu of a policy for MDS completion.
Failure to Follow Fall-Risk Care Plan Interventions
Penalty
Summary
The facility failed to implement care plan interventions for 2 residents reviewed for falls. Resident 6 had diagnoses including renal failure, dementia, anxiety, and psychotic disorder, and the most recent significant change MDS indicated severe cognitive impairment, no behaviors, and substantial to maximum assistance needed for eating, toileting, bed mobility, showers, and transfers. The resident’s current fall risk care plan included bringing the resident to the common area after meals and toileting before and after meals, but on observation the resident remained at the dining room table for 43 minutes after lunch ended before being taken back to the room. When the resident was transferred from the wheelchair to the bed, the brief was checked, and CNA 21 stated they did not currently offer toileting because the resident was incontinent. Resident 35 had diagnoses including dementia, anxiety, depression, and psychotic disorder, and the most recent significant change MDS indicated severe cognitive impairment and no behaviors, with partial to moderate assistance needed for toileting and showers and supervision or touching assist for bed mobility and transfers. The resident’s fall risk care plan included keeping the call light in reach and placing Dycem under dining room table legs in common areas. On observation, the resident was sitting in a recliner with the call light coiled on the floor out of reach, and the dining room and common area furniture were observed without Dycem under the legs.
Failure to Update Fall Care Plans After Repeated Resident Falls
Penalty
Summary
The facility failed to revise residents’ fall care plans with new interventions after multiple falls for 3 of 3 residents reviewed. The deficiency involved Resident 17, Resident 6, and Resident 35, all of whom had significant cognitive impairment documented on recent MDS assessments and required varying levels of assistance with toileting, transfers, bed mobility, showers, and ambulation-related activities. The record review showed that each resident had a current falls care plan with existing interventions, but new interventions identified after subsequent falls were not added in a timely manner or were not added at all. Resident 17 had several falls documented in the clinical record. After a fall when the resident lost balance walking with a walker, the record lacked a new falls intervention. After another fall when the resident was found sitting on the buttocks beside the bed, staff noted to encourage gripper socks as a fall prevention measure, but that intervention was not added to the care plan for 21 days. Two additional falls occurred later, including one where the resident was found lying on the floor beside the bed with a red bruise to the left forearm and wet floor, and another where the resident was found on the floor in front of the bed; the record lacked new care plan interventions after both events. Resident 6 had falls on two occasions, including being found lying on the floor next to the bed during bed checks and later being found sitting on the floor next to a roommate’s bed with a skin tear to the left elbow. The immediate interventions noted were a low bed and encouragement to wear gripper socks in bed, but the record lacked a new falls care plan intervention after each fall. Resident 35 also had two falls, including being found scooting on the floor toward a doorway in another resident’s room and later sitting on the buttocks on the floor near the bed. Staff noted to ensure the resident wore gripper socks when not wearing shoes, but the clinical record lacked an updated care plan intervention after the falls. The DON stated that after a resident experienced a fall, an IDT meeting should be held the next morning or the following Monday if on a weekend, and any new falls interventions discussed should be placed into the care plan that same day.
Failure to Follow Insulin Orders and Document Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure physician orders were followed for insulin administration and blood glucose monitoring for residents with diabetes. During observation of medication administration, Resident 2 was seen receiving Humalog insulin for a blood sugar of 537, but the nurse dialed the pen to 9.0 units and administered that amount even though the sliding scale order called for 9.5 units for a blood sugar of 501-600. The nurse stated the pen only allowed one-unit increments and did not call the physician for clarification before giving the wrong dose. Resident 2 had diagnoses including dementia and diabetes mellitus type II, and the care plan directed staff to administer antidiabetic medications per order. Record review for Resident 2 also showed that the Medication Administration Record for September 2025 documented 9.5 units of Humalog as given for the noon dose on 9/8/25, even though 9.0 units had been administered. On 9/12/25, RN 16 stated medications should be given as ordered and clarified if there was confusion, and that the dose entered in the MAR reflected what should have been given rather than what was actually administered. The nurse indicated she was going to call the MD for clarification of the sliding scale order and stated the dose given should be documented in the MAR. Resident 8’s record showed diabetes mellitus and orders for Lantus 5 units in the morning and insulin lispro 6 units four times daily, along with orders to check blood sugars and administer medications per order. The MAR showed multiple instances over a three-month look-back period where blood glucose monitoring was not completed and insulin was not given, with the MAR left blank on several dates and times for both insulin lispro and Lantus. The DON stated she could not find documentation explaining why the insulin had not been documented, and the Regional Clinical Support stated that if a medication is refused or not given for another reason, codes should be entered in the MAR to indicate why it was not given.
Failure to Maintain Hand Hygiene and Clean Technique During Medication Passes and Incontinence Care
Penalty
Summary
The facility failed to ensure staff provided a sanitary environment to help prevent the development and transmission of communicable diseases and infections during medication administration and incontinence care. During medication passes, an LPN was observed prepping medications for one resident and did not sanitize hands before or after the pass, then later washed hands with only a seven-second lather after administering medications to another resident. An RN was observed prepping medications for a resident and did not sanitize hands before or after the medication pass, and a QMA was observed prepping medications for another resident and also did not sanitize hands before or after the medication pass. During incontinence care for one resident, a CNA used gloved hands to touch multiple items in the room, including the bed remote, call light, drawer, wipes, and trashcan, without changing gloves or performing hand hygiene between dirty and clean tasks. The CNA wiped the resident’s perineal area and bowel movement with the same gloves, ran out of wipes, and left the resident with a brown substance still on the buttocks. The CNA then removed one glove, tucked a clean brief under the resident with the remaining gloved hand, fastened the brief, removed the other glove, and failed to perform hand hygiene before pulling up the blankets and lowering the bed.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to post up-to-date nurse staffing information on the posted nurse staffing form for 6 of 6 days reviewed. On each observed day, the form by the nurse's station was dated the prior day or otherwise not current, and the evening shift from 2:00 P.M.-10:00 P.M. had no nursing staff listed. The forms also did not list specific hours worked for nursing staff as required. The posted staffing information reviewed on 9/7/25, 9/8/25, 9/9/25, 9/10/25, 9/11/25, and 9/12/25 showed varying staffing entries for day and night shifts, including RNs, LPNs, CNAs, and QMAs, but the evening shift was left blank on each form. During interview, an LPN stated she arrived at 7:00 A.M., was the only nurse on the floor at that time covering both the memory unit and the front area, and would leave at 1:00 P.M.; she also stated the night nurse left at 7:00 A.M. and an RN would not arrive until 11:00 A.M., with one QMA working on the floor. Regional Clinical Support stated the facility did not update the posted nurse staffing forms for accuracy until the next day and was unaware the information needed to be updated in real time while posted. The facility's posted nurse staffing policy stated the facility must post daily, at the beginning of each shift, the facility-specific shift schedule for the 24-hour period and update data as changes arise.
Failure to Accurately Transcribe and Administer Routine Medication Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure the accurate receiving and administration of routine medications for a resident with a diagnosis including unspecified polyneuropathy and moderate cognitive impairment. The resident had physician's orders for Lyrica at specific dosages and times, but due to an incorrectly entered order by facility staff, the resident experienced an interruption in their routine medication and an unprescribed dosage reduction. The medication administration record showed missed doses of Lyrica at various times, and progress notes documented that the resident did not receive the medication as ordered, with pharmacy communication issues and delays in medication delivery. The resident reported increased pain in their legs and feet during the period of reduced medication, and staff confirmed that the change in Lyrica dosage was made without physician authorization. Interviews with nursing staff revealed that the original physician order was entered incorrectly into the electronic record, resulting in the resident receiving less medication than prescribed. Facility policy required that all physician orders be implemented and followed as received, but this was not adhered to in this instance.
Inadequate Staffing and Documentation on Dementia Unit
Penalty
Summary
The facility failed to ensure adequate staffing on the Memory Springs locked dementia unit, as observed during a survey. Over two days, a licensed nurse was not stationed on the unit, and the monitoring and documentation of resident behaviors were not completed over a 30-day review period. The staffing patterns did not align with the facility's Alzheimer's/Dementia Special Care Unit staffing specifications. Observations revealed that the unit was staffed with only one CNA and one activity assistant, with the nurse floating from another part of the building. The daily schedule confirmed the absence of nursing staff and QMAs on the unit during various shifts. Resident C, who has severe cognitive impairment and a history of wandering, exhibited behaviors such as physical aggression and public sexual acts, which were not consistently documented in the nurse's notes. Despite physician orders for behavioral monitoring every shift, there were gaps in documentation, and a facility investigation revealed that inappropriate behaviors were not recorded on several occasions. The lack of adequate staffing and documentation compromised the monitoring of Resident C's behaviors. Resident D, diagnosed with severe cognitive impairment and behavioral disturbances, was found in another resident's bed after being unaccounted for. Despite physician orders for behavioral monitoring, there was no documentation of Resident D's behavior on the night of the incident or of their sadness on a subsequent date. Interviews with staff indicated that behaviors should be documented in the clinical record, but this was not consistently done. The facility lacked a policy related to staffing, contributing to the deficiencies observed.
Failure to Monitor and Document Dementia-Related Behaviors
Penalty
Summary
The facility failed to provide necessary treatment and services for two residents diagnosed with dementia, leading to deficiencies in monitoring and documentation of resident behaviors. Resident C, diagnosed with Alzheimer's disease and vascular dementia, exhibited severe cognitive impairment and daily wandering. Despite physician orders for behavioral monitoring and a care plan addressing inappropriate sexual comments, there was a lack of documentation in the nurse's notes regarding Resident C's sexually inappropriate behaviors on multiple occasions. Additionally, the facility's investigation revealed that staff were aware of these behaviors, yet they were not consistently documented or addressed in the resident's clinical record. Resident D, also diagnosed with dementia and severe cognitive impairment, was found in another resident's bed, indicating a failure to monitor wandering behaviors effectively. Although Resident D's care plan included monitoring for behavioral symptoms and mood decline, there was no documentation of the resident's behavior on the night of the incident or of the resident's sadness and tearfulness on a subsequent date. The facility's policy on handling behavioral emergencies emphasized the need for documentation and monitoring of interventions, which was not adhered to in these cases.
Inaccurate Documentation of Resident Records
Penalty
Summary
The facility failed to ensure accurate documentation of resident records for three residents, leading to discrepancies in the medical records. For Resident B, the neurological evaluation flow sheet lacked staff initials for neuro checks conducted after an unwitnessed fall, and all entries appeared to be in the same handwriting. Resident C's records showed that the Assistant Director of Nursing (ADON) and the MDS Coordinator had initialed neuro checks at times when they were not scheduled to work, according to the facility's work schedules. Similarly, Resident D's records indicated that the ADON and MDS Coordinator had initialed neuro checks outside of their scheduled shifts, with no documentation to support their presence in the facility at those times. During interviews, the MDS Coordinator mentioned that they sometimes visited the facility outside of scheduled hours, which might explain the discrepancies. The ADON admitted that Qualified Medication Aides (QMAs) sometimes collected vital signs, which were later recorded by the ADON. However, there was no documentation to verify these claims. The facility lacked a current policy for accurate documentation, although a Nurse Job Description was provided, which outlined the requirement for signing and dating all entries in residents' medical records.
Failure to Notify Physician of Critical Changes
Penalty
Summary
The facility failed to notify the physician regarding the need to alter treatment for two residents who were reviewed for unnecessary medications. For Resident 30, the facility did not notify the physician of elevated blood sugar readings and significant weight changes. The resident's clinical record showed multiple instances of elevated blood sugar levels, some exceeding 500 mg/dL, and significant weight fluctuations, yet there was no documentation of physician notification. The Director of Nursing (DON) acknowledged that the staff should have notified the physician when blood sugar levels exceeded 450 mg/dL and when there were significant weight changes. Resident L also experienced elevated blood sugar levels, with readings frequently exceeding 400 mg/dL, yet the facility failed to notify the physician. The resident's clinical record lacked documentation of blood sugar parameters for physician notification, and the Medication Administration Record (MAR) did not indicate that the physician was informed of the high blood sugar levels. The Assistant Director of Nursing (ADON) confirmed that staff should notify the physician if blood sugar levels exceed 400 mg/dL and document the notification in progress notes. Additionally, the facility failed to notify the physician of missed doses of Cefepime for Resident F, who was being treated for a urinary tract infection. The Medication Administration Record indicated that several doses were not administered as ordered, and there was no documentation of physician notification or investigation into the missed doses. The DON confirmed that the physician had not been notified of the missed doses, which was against the facility's policy for medication administration errors.
Inadequate Infection Control and Documentation
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment to prevent the development and transmission of infections. During a review of the facility's infection tracking binder for July, August, and September 2024, it was found that urinary tract infections (UTIs) for three residents were not documented. Resident K had a UTI in July 2024, Resident J in August 2024, and Resident G in both August and September 2024. The Infection Preventionist admitted that these infections were not tracked due to an inability to complete the documentation, which should have included the resident's name, date, and type of infection. In a separate observation, the facility staff failed to adhere to proper hand hygiene and glove use protocols during incontinence care for Resident M. CNA 7 and RN 5 were observed performing care with inadequate handwashing times and improper glove use. CNA 7 touched various items with gloved hands before and after performing care, failed to change gloves or perform hand hygiene between tasks, and used soiled gloves to touch clean items. RN 5 also did not follow proper hand hygiene protocols, washing hands for only 6 seconds. The facility's policies on perineal care, glove use, and hand hygiene were not followed during this care episode. The facility's Infection Prevention and Control policy, which includes a surveillance system to identify and record infections, was not effectively implemented. The policy requires identifying possible communicable diseases before they spread and maintaining a recording system for infection incidents. However, the facility failed to track and document infections accurately, as evidenced by the missing UTI records. This deficiency was identified in relation to a specific complaint, indicating a lapse in the facility's infection control practices.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their medical needs. Resident 18, who has diagnoses including diabetes mellitus type II, generalized anxiety disorder, borderline personality disorder, and bipolar disorder, was found to lack care plans for antianxiety, antipsychotic, antiplatelet, and diabetes medications. Despite having physician's orders for medications such as Latuda, Buspar, Aspirin, Jardiance, and Metformin, the clinical record did not include corresponding care plans to manage these conditions effectively. Similarly, Resident 30, with diagnoses of chronic obstructive pulmonary disease, atherosclerotic heart disease, hypertension, and nicotine dependence, lacked a care plan for smoking/vaping and a no added salt (NAS) diet restriction. Although a dietary progress note recommended adding an NAS restriction due to significant weight gain, this order was not implemented. The Director of Nursing acknowledged the oversight and indicated that the process for implementing dietary recommendations was not followed, as there was no policy in place to ensure such orders were executed promptly.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident with chronic obstructive pulmonary disease (COPD). The resident was observed receiving oxygen via nasal cannula at 3 liters per minute (LPM) without proper monitoring of oxygen saturation (O2 sat) levels or the frequency and amount of oxygen used. The clinical record lacked a comprehensive care plan for oxygen use, and there were no parameters set for staff to determine the accurate LPM needed. Observations showed the resident wearing the nasal cannula incorrectly, and staff did not address or correct this issue. The Director of Nursing (DON) indicated that there should have been a care plan and orders for staff to check the resident's O2 sats on room air every shift and as needed for shortness of breath. However, the resident's vitals, including O2 sat, were not consistently checked every shift, and the reason for discontinuation was unknown. The facility's policy required oxygen saturation levels to be measured per physician order and documented every shift, but this was not adhered to, leading to the deficiency.
Failure to Document Food Temperatures
Penalty
Summary
The facility failed to serve food in accordance with professional standards for food service safety, as observed during a survey. The food temperature logs for the period from 9/5/24 to 9/23/24 were reviewed, revealing that food temperatures were not documented for 12 out of 19 days. Specifically, there were no recorded temperatures for dinner on several dates, and on two occasions, no temperatures were recorded for breakfast, lunch, or dinner. The Dietary Manager acknowledged that if temperatures were not documented, it likely meant they were not taken, attributing this lapse to newer staff who may require re-education on the importance of recording food temperatures before serving. The facility's Monitoring Food Temperatures Policy, provided by the DON, mandates that food temperatures be monitored daily to prevent foodborne illness. It specifies that temperatures for all hot and cold foods should be recorded on the Food Temperature Log before serving. Hot foods must be at least 135 degrees Fahrenheit, and cold foods should be 41 degrees Fahrenheit or below. The failure to adhere to this policy was identified as a deficiency during the survey.
Failure to Document and Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to administer or properly document the pneumococcal immunization for three residents. Resident 20, who was severely cognitively impaired, had received the Prevnar-13 vaccine but lacked documentation for a second dose. The Director of Nursing acknowledged that Resident 20 should have received a second pneumococcal vaccine. Resident 5, with moderate cognitive impairment, had a signed consent form for the pneumococcal vaccine, but there was no documentation of the vaccine being offered, ordered, administered, or refused since the consent was signed. Similarly, Resident 4, who was cognitively intact, had a signed consent form, but the clinical record lacked documentation of the vaccine being ordered, administered, or refused. The facility's policy on pneumococcal vaccination was undated and stated the intent to minimize the risk of residents acquiring or transmitting pneumococcal pneumonia. It required documentation of information provided to residents or their representatives regarding the risks and benefits of the vaccine, as well as documentation of administration, refusal, or medical contraindication. However, the facility failed to adhere to this policy, as evidenced by the lack of documentation in the clinical records of the three residents reviewed.
Failure to Follow Physician Orders and Update Care Plans
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards and a comprehensive person-centered care plan for a resident with bowel and bladder incontinence. The resident, diagnosed with cellulitis of the right lower limb, was not given care as per physician orders, and the physician was not notified of changes in the resident's condition. Treatments were administered without proper orders, care plans were not updated, and wound assessments were not completed. The resident's clinical record indicated a lack of cognitive impairment, frequent bowel incontinence, and a need for extensive assistance with toileting. Physician orders for the resident included stool occult tests every 12 hours for infection control, which were not consistently obtained or documented. The resident experienced an adverse reaction to an antibiotic, resulting in loose stools and skin maceration. Despite this, the facility failed to notify the physician about the inability to obtain stool samples and did not update the care plan to reflect the resident's new skin issues. The Medication Administration Record (MAR) showed multiple instances where stool samples were not obtained, and the clinical record lacked documentation of stool occult test results or lab submissions. Interviews with facility staff revealed a lack of communication and coordination in managing the resident's care. Certified Nurse Aide (CNA) 9 was unaware of the need for stool tests, while Registered Nurse (RN) 3 acknowledged the issue but noted that the resident was no longer experiencing diarrhea. The Director of Nursing (DON) admitted that the physician should have been notified about the missed stool samples and that there was no current facility policy related to wound management. The DON also noted that the resident's skin integrity care plans should have been updated upon returning from the hospital with new skin issues.
Deficient Pressure Ulcer Care in LTC Facility
Penalty
Summary
The facility failed to provide adequate care for a resident with chronic pressure ulcers, leading to deficiencies in wound management and prevention of new ulcers. The resident, who had diagnoses including paraplegia and diabetes mellitus, required extensive assistance with mobility and had two stage 4 pressure ulcers. The care plan interventions were not followed, as orders for wound care were not placed, pressure ulcers were not staged correctly, and dressings were not completed as ordered. The resident's Medication Administration Record (MAR) indicated multiple instances where wound treatments were not performed, and there was a lack of documentation explaining these omissions. Skin assessments were not conducted as scheduled, and the clinical record lacked documentation of wound assessments for significant periods. Additionally, new treatment orders for pressure ulcers were not placed or initiated, and the facility did not have a current policy for the prevention and treatment of pressure ulcers. The Director of Nursing (DON) acknowledged that wound assessments were not part of the clinical records and had not been documented appropriately. The DON also noted that the right buttock pressure ulcer was mis-staged, and wound evaluations were not conducted weekly as required. Furthermore, the facility lacked Interdisciplinary Team (IDT) meetings or notes related to the resident's pressure ulcers, and there was only one care plan in place for multiple pressure ulcer areas, which should have been separated.
Failure to Prevent Falls and Update Care Plans
Penalty
Summary
The facility failed to provide adequate supervision and prevent falls for a resident identified as being at risk for accidents. The resident, who had severe cognitive impairment and required supervision for mobility and toileting, experienced two unwitnessed falls. After these falls, the facility did not complete necessary neurological assessments or update the resident's care plan. Additionally, the fall risk assessments were either not completed or were done incorrectly, failing to account for the resident's use of psychotropic medication. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed that the required procedures following a fall, such as neuro checks and care plan updates, were not followed. The facility's policies clearly stated that neuro checks should be conducted after any unwitnessed fall and that each fall should prompt a new care plan intervention. However, these protocols were not adhered to, leading to the identified deficiency.
Failure to Administer IV Antibiotic for UTI
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of an intravenous antibiotic for a urinary tract infection (UTI). The resident, who had a diagnosis of obstructive uropathy and an indwelling catheter, was prescribed Cefepime to be administered intravenously every six hours for seven days. However, the Medication Administration Record (MAR) indicated that four doses of Cefepime were missed on specific dates and times, with no accompanying nurse notes to explain the omissions. Furthermore, the clinical record lacked documentation of physician notification regarding the missed doses, and there was no investigation conducted to determine the cause of the medication errors. The Director of Nursing (DON) confirmed the absence of nurse notes and physician notification, as well as the lack of an investigation into the missed doses. The facility's Medication Administration Errors policy requires that upon identification of a medication error, a report form should be completed, the physician and family notified, and an investigation conducted, none of which were done in this case.
Medication Storage Deficiency
Penalty
Summary
The facility failed to maintain safe and secure storage of medications, specifically for one of the two medication carts observed. During an observation, it was noted that the narcotic lock box on the medication cart located in the 100/200 hall was unlocked. The Assistant Director of Nursing (ADON) acknowledged that the lock box should have been secured. The Director of Nursing (DON) later provided a current Medication Storage in the Facility policy, dated February 2017, which stated that all drugs classified as Schedule II of the Controlled Substances Act must be stored under double locks.
Failure to Update Nurse Staffing Sheets Daily
Penalty
Summary
The facility failed to ensure that the posted nurse staffing sheets were updated and contained the correct information daily. On September 24, the posted nurse staffing information was observed to be outdated, displaying the date of September 19. During an interview, the Director of Nursing (DON) indicated that the Assistant Director of Nursing (ADON) was responsible for filling out and checking the posted nurse staffing form daily, with the night shift tasked with updating it each night. However, the form was not current as required. The facility's policy, as per the Benefits Improvement and Protection Act of 2000 (BIPA) Staffing Posting Requirements, mandates that skilled nursing facilities (SNFs) and nursing facilities (NFs) must post the facility-specific shift schedule daily at the beginning of each shift, including the current date.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor and manage a resident's drug regimen, leading to the administration of psychotropic medications beyond the recommended 14-day period without documented rationale. The resident, who had a history of unspecified dementia with behavioral disturbances, depression, and other conditions, was given as-needed psychotropic medications without proper documentation or assessment to justify their continued use. The facility's records showed that behavior monitoring was inconsistent, with several instances where behavior monitoring was marked as 'n' or 'NA' or left blank, indicating a lack of proper documentation and follow-up on the resident's condition. The resident's care plans included the use of psychotropic medications to manage symptoms such as psychosis, depression, and anxiety. However, the facility did not consistently follow through with behavior management techniques or document the effectiveness of interventions before administering medications. The EMAR for several months showed gaps in behavior monitoring, and the facility's policy required that PRN orders for psychotropic drugs be limited to 14 days unless a physician documented a rationale for extending the medication. This policy was not adhered to, as evidenced by the lack of documentation supporting the continued use of these medications. Additionally, the facility failed to conduct an EKG as ordered for the resident due to the use of Geodon, an antipsychotic medication. The EKG was not performed until the resident was sent out for behaviors, which was not in compliance with the physician's orders. Interviews with staff, including the ADON and RN, revealed that there was no assessment or documentation to justify the continuation of psychotropic drugs beyond 14 days, and behavior monitoring was not consistently recorded in the EMAR. This lack of adherence to policies and procedures contributed to the deficiency identified in the report.
Failure to Implement Dementia Care Plan and Physician Orders
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident diagnosed with dementia, leading to inappropriate sexual behaviors. Resident B, who had severe cognitive impairment and required supervision, exhibited inappropriate sexual behaviors towards other residents in a locked dementia unit. Despite having a care plan that included interventions for sexual behaviors, the facility did not update the plan or implement physician orders following incidents involving Resident B and other residents. On two separate occasions, Resident B was involved in incidents of inappropriate touching with other residents. The first incident involved Resident B kissing and making contact with another resident's breast, while the second incident involved inappropriate touching of another resident. Although a Climara patch was ordered to manage Resident B's behaviors, it was not administered as directed. The facility's staff chose not to apply the patch, and there was no documentation of an alternate plan or lasting interventions to prevent further incidents. The facility's investigation revealed that the nursing staff did not implement the ordered Climara patch and instead moved one of the involved residents to another unit. The facility's policy on behavior management was not effectively followed, as there was no evidence of clinical and psychosocial interventions being determined to address Resident B's needs. The lack of action and failure to follow physician orders contributed to the continuation of inappropriate behaviors by Resident B.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to provide proper foot care for five residents, resulting in long, thick, and curling toenails, as well as ingrown toenails. Resident B had been trying to see a podiatrist for three months due to sore and ingrown toenails but was told there was an issue with her insurance. Her clinical records lacked any care plans or notes related to foot care, and she had not seen a podiatrist. The Administrator later indicated that the facility did not deny services based on insurance issues and would investigate further. Resident C had never seen a podiatrist since being in the facility and had long, thick toenails that were starting to curl. He was told that insurance would not cover the service. His clinical records also lacked any care plans or notes related to foot care. The Administrator was unsure if Resident C was diabetic and mentioned that the podiatrist visited every 61 days, which might coincide with Resident C's dialysis schedule. Resident D had toenails curled over every toe, and his family member was cut by one of his nails. His clinical records lacked any care plans or notes related to foot care. Resident F had long toenails, and the CNA was unaware of their condition. His clinical records indicated that his toenails were trimmed once but lacked any further notes on foot care. Resident E had thick, long, yellow, and crusty toenails. Although he was on hospice, there was confusion about whether ancillary services like podiatry were still provided. The podiatrist had been requested not to see Resident E due to her being on hospice, despite her being on the list for the visit.
Facility Fails to Ensure Comfortable Environment Due to Sticky Floors
Penalty
Summary
The facility failed to ensure a comfortable environment for residents, staff, and the public, as evidenced by sticky floors in 11 of 29 observed rooms. The issue was first noted in resident council meeting minutes on 8/2/23, and subsequent observations on 2/1/24 confirmed the persistence of sticky floors in multiple rooms. Interviews with the Housekeeping Supervisor, an LPN, and the Activities Assistant revealed that the stickiness was attributed to the reaction of cleaning chemicals with the floor wax, exacerbated by heat and humidity. The Housekeeping Supervisor acknowledged the difficulty in removing old wax from the original tile floors, which contributed to the problem. Despite these ongoing issues, there was no written plan to address the floor stickiness, and progress on replacing the flooring with vinyl was slow due to the workload and daily maintenance needs of the facility staff responsible for the task. Residents and staff consistently reported the discomfort caused by the sticky floors. The Activities Director had communicated the resident council's complaints to housekeeping and the Administrator, who downplayed the issue by attributing it to cleaning chemicals. However, the Administrator and Maintenance Supervisor admitted that there was no formal plan or estimated completion date for resolving the floor stickiness. The facility staff, including the Administrator, Maintenance Supervisor, and Housekeeping Supervisor, were working on laying new vinyl flooring in some rooms, but the progress was hindered by other maintenance responsibilities. This deficiency was related to Complaint IN00422428.
Failure to Provide Proper Perineal Care
Penalty
Summary
The facility failed to ensure dependent residents received the necessary services to maintain good grooming and personal hygiene for two residents. In the first instance, a CNA continued to wipe a resident during perineal care after the resident complained of pain. The resident, who had a history of morbid obesity, asthma, depression, spinal stenosis, and hypertension, indicated that the CNA had previously used a dry washcloth aggressively, causing pain. Despite the resident's complaints, the CNA continued the care, leading to further discomfort. The resident's clinical records and care plan indicated the need for pericare after every incontinent episode and assistance with toileting, but these were not adequately followed, resulting in the resident experiencing pain and discomfort during care. In the second instance, another CNA did not wipe appropriately for a resident with severe cognitive impairment and frequent incontinence of the bladder. During incontinence care, the CNA wiped the resident's labia in a manner that caused pain, and despite the resident's complaints, the CNA continued to wipe the area, which was observed to be red. The resident's care plan included providing proper hygiene and infection control, but this was not adhered to, leading to the resident experiencing pain and discomfort. The facility's policy indicated that staff should stop immediately and notify the nurse if a resident complained of pain during care, but this protocol was not followed in both cases.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to ensure proper infection control practices during the provision of perineal care and bed baths for three residents. Specifically, staff members did not wash their hands for the recommended 20-30 seconds, and they failed to change gloves between dirty and clean tasks. For instance, during incontinence care for Resident E, CNA 2 and CNA 4 did not wash their hands adequately and used the same gloves to touch various surfaces and perform different tasks. Similarly, during incontinence care for Resident D, CNA 2 did not wash hands or sanitize before putting on new gloves after removing dirty ones. Additionally, during a bed bath for Resident B, both CNAs did not change gloves after touching potentially contaminated surfaces and did not wash their hands for the required duration. The facility's current hand hygiene policy requires a 20-second lather with soap, and the gloves policy mandates hand hygiene between the removal of used gloves and the application of new ones. However, these protocols were not followed, as evidenced by the observations of the CNAs' practices. The failure to adhere to these infection control practices was confirmed through interviews with staff members, who acknowledged the correct procedures but did not follow them during care. This non-compliance with established infection control policies poses a risk of infection to the residents.
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Illustrative
What surveyors actually found near you
We read the 87 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Huntingburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookside Village Inc | 5.1 mi | ★★★★★ | 4 | 0 |
| Cathedral Health Care Center | 5.8 mi | ★★★★★ | 0 | 0 |
| Serenity Spring Senior Living At Northwood | 7 mi | ★★★★★ | 2 | 0 |
| Timbers Of Jasper The | 7.2 mi | ★★★★★ | 3 | 0 |
| St Charles Health Campus | 7.3 mi | ★★★★★ | 0 | 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.