Heritage Grove at Indiana.

“The resident/home contract for a resident was not signed by the resident as required.”

“A resident record did not contain a statement signed by the resident acknowledging receipt of a copy of the resident rights and complaint procedures.”

“Direct care staff roughly transferred a resident from bed to wheelchair, causing physical injury and distress. The resident reported the staff member twisted the resident's arm, causing the resident to cry for approximately 20 minutes. This is a repeat violation.”

“A resident admitted did not have a pre-admission screening form completed within 30 days prior to admission to document that the resident's needs can be met by the services provided by the home.”

“A resident who participated in the development of a support plan did not sign and date the support plan as required.”

“The home's most recent fire safety inspection and supervised fire drill conducted by a fire safety expert was completed on 2/29/24, but annual documentation was not kept current.”

“Fire drill log records contained incorrect numbers of residents in the home at the time drills were conducted on the following dates: 2/25/24 (recorded 33 vs. actual 31), 10/31/24 (recorded 36 vs. actual 30), 1/31/25 (recorded 33 vs. actual 31), and 2/27/25 (recorded 39 vs. actual 37).”

“Direct care staff member A and ancillary staff member B did not complete required annual training in 2025: resident rights, the Older Adult Protective Services Act, and falls and accident prevention.”

“Resident #1 was prescribed Jardiance 10 mg, Entresto 24-26 mg, and Spironolactone 25 mg daily, but these medications were not administered from 5/7/25 to 5/13/25. These medication errors were not reported to the Department within 24 hours as required. This is a repeat violation.”

“No carbon monoxide detectors were present near the gas dryer in the laundry room as required by The Care Facility Carbon Monoxide Alarms Standards Act, which requires CO alarms to be installed in close proximity to, but not less than 15 feet from, any fossil-fuel burning device or appliance.”

“Direct care staff member A did not complete required annual training topics in 2024: care for residents with dementia and cognitive impairments, infection control and general principles of cleanliness and hygiene, personal care service needs of the resident, and safe management techniques.”

“Sanitary conditions were not maintained: a used adhesive bandage was found in a shower drain in the Secure Dementia Care Unit, and five unlabeled bars of used soap were found in the SDCU shower room.”

“Fire drill records show evacuation times exceeding 2 minutes 30 seconds (3/29/24: 4 min 56 sec; 4/30/24: 4 min 38 sec; 5/29/24: 9 min), but there is no documentation from a fire safety expert since 2/29/24 indicating that a maximum safe evacuation time exceeds 2 minutes 30 seconds.”

“Resident prescribed medications were not administered on the scheduled date because the medications were not available in the home. This was a repeat violation.”

“Resident's initial support plan upon admission to the Secured Dementia Care Unit was not dated and therefore not documented as developed within 72 hours of admission.”

“The resident's support plan did not address the resident's elopement from the Secured Dementia Care Unit or the resident's increased problems with judgment, both of which are safety needs.”

“A resident incident involving a laceration above the left eye was not reported to the Department within the required 24 hours. The incident occurred at approximately 1:58 a.m., but was not reported until 10:00 a.m. on a subsequent date, exceeding the 24-hour reporting requirement.”

“A resident prescribed one tablet of medication twice daily as needed for anxiety was administered a total of 5 doses in a 24-hour period. Staff member A administered the medication inconsistent with the prescriber's order to keep the resident from ringing the call bell at night and to sedate the resident, constituting chemical restraint and abuse/neglect.”

“A medication administration record was incomplete. Staff member A administered one dose of medication to a resident at 5:46 a.m., but the staff member's initials were not documented in the corresponding date/time field on the November 2024 medication administration record.”

“The home failed to follow the prescriber's orders for a resident's medication prescribed as one tablet orally twice daily as needed for anxiety. The resident was administered a total of 5 doses in a 24-hour period, with staff member A administering doses inconsistent with the prescription to sedate the resident and prevent call bell ringing.”

“A chemical restraint was used when a resident prescribed one tablet of medication twice daily as needed for anxiety was administered a total of 5 doses in a 24-hour period by staff member A for the purpose of controlling the resident's behavior and sedating the resident rather than treating the resident's anxiety condition as prescribed.”

“Staff person A threw a resident's shirt, hitting the resident in the face during a dressing assistance incident. This allegation of abuse was not reported in accordance with the Older Adult Protective Services Act until October 13, 2024 at approximately 3:00 p.m., rather than immediately as required.”

“An incident involving alleged abuse (staff person A throwing a resident's shirt and hitting the resident in the face) was not reported to the Department within 24 hours as required; the incident was not reported to the Department until 4:38 p.m. on an unspecified date.”

“A resident was not treated with dignity and respect when staff person A threw the resident's shirt, hitting the resident in the face, during a dressing assistance incident on the morning of the violation date.”

“Resident-home contracts for residents #1 and #2 were not signed by the residents and did not notate that residents were given the opportunity to sign. Contracts for residents #3 and #4 lacked addendums reflecting the change of legal entity and updated contract terms.”

“Resident #4's record did not contain a statement signed by the resident acknowledging receipt of a copy of resident rights and complaint procedures.”

“The home routinely has only 2 staff persons working the 10:00 pm-6:00 am shift for 34 residents. In the event of an emergency evacuation, staffing is inadequate to meet evacuation and supervision needs, particularly given 18 residents with mobility needs including 10 in the secured dementia care unit and 3 residents requiring 2-person physical assistance.”

“On 4/21/24 and 4/27/24 from 10:00 pm-6:00 am with 34 residents present, no staff certified in first aid were on duty. On 5/5/24 from 10:00 pm-6:00 am with 35 residents present, no staff certified in first aid were on duty.”

“On 5/7/24 at 10:35 am, the hot water temperature at the sink in the shared bathroom for bedrooms #201 and #202 measured 125.4 degrees Fahrenheit, exceeding the 120°F maximum.”

“A resident's bedrail measured 19.5 inches by 6 inches with an uncovered opening of 18 inches by 6 inches, posing a potential entrapment hazard. Wheelchairs, walkers, and other apparatus must be clean, in good repair, and free of hazards.”

“The resident medical evaluation did not include an order for the use of the bedrail which is currently on the resident's bed. Medical evaluations must include medication regimen and orders for any medical equipment in use.”

“The home's designated staff smoking area had chairs and an ashtray set up directly outside emergency exit #4, violating the requirement that smoking areas be located a safe distance from heat sources, combustible materials, and away from common walkways and exits.”

“Over-the-counter medication was found sitting on the nightstand in a shared bedroom of two residents, but these residents had not been assessed by a physician, physician's assistant, or certified registered nurse practitioner regarding their ability to self-administer medications and need for medication reminders.”

“The resident support plan did not document how the home will meet the resident's need for the use of a bedrail and the associated safety risks and precautions involved. Support plans must document medical and other health care services to be made available to residents.”