Arbor Grove Village: Medication Safety Failures - IN
That finding was one of two medication failures federal inspectors documented during an April 2026 inspection of the Greensburg nursing facility.
The resident, identified in inspection records as Resident 77, was assessed in March 2026 as severely cognitively impaired. Her diagnoses included metabolic encephalopathy, a brain dysfunction caused by underlying conditions such as liver failure, kidney failure, or diabetes that disrupt normal brain chemistry, and adult failure to thrive. She had been prescribed Megestrol Suspension, 400 milligrams twice a day, to address that failure to thrive directly.
She didn't get it.
Records showed the medication was simply unavailable on the evening of February 25, the morning of February 26, and the evening of February 26, 2026. Three consecutive doses, gone. She also missed three doses of Sodium Chloride, 1,000 milligrams three times a day, on March 2 and March 3. Each time, her medication administration record logged the drugs as unavailable. Each time, her physician was not notified.
A registered nurse interviewed by inspectors on April 24 laid out exactly what should have happened. If a medication wasn't in the cart, she said, staff should check the emergency drug kit. If it wasn't there either, they should order it stat, which would bring it within two to four hours. Daily deliveries ran between 6 and 8 in the morning. And if none of that worked, the physician should be notified. She said she would document that notification in the electronic medication record or in progress notes.
For Resident 77, that documentation didn't exist. Inspectors reviewed the clinical record and found no physician notification related to the missing medications at all.
The second violation involved a different resident and a different kind of breakdown, one rooted in a handoff that never should have happened.
On the morning of April 23, a registered nurse, RN 11, went to Resident 82's room to perform a treatment. When she arrived, there was already a medication cup sitting on the resident's over-the-bed table. It contained two pink tablets. A nurse in training, a licensed practical nurse identified as LPN 12, had prepared the medications and brought them to the room before RN 11 arrived. RN 11 had actually asked her to wait before giving the resident anything, intending to finish the treatment first. But the cup was already there.
RN 11 gave the resident the tablets.
When inspectors interviewed her later that morning, she identified the tablets as antacids. She also acknowledged the standard practice at the facility: the nurse who prepares the medication is the nurse who administers it. That's not just custom. The facility's own medication administration policy, revised as recently as April 2025, requires staff to observe the resident taking medications, a step that assumes the same person who prepared the dose is present to watch it go down.
Resident 82 had been admitted with diagnoses including stricture of artery and peripheral vascular disease, a progressive circulation disorder involving narrowing or blockage in blood vessels. The inspection record does not indicate the antacids caused her harm. But the inspection record also doesn't need to establish harm for the violation to matter. A nurse administered medications she didn't prepare, in a room she entered after the fact, with a medication cup that had been sitting unattended on a table.
Inspectors rated both violations at the minimal harm level, meaning no serious injury was documented. Arbor Grove Village was cited under Indiana Administrative Code governing pharmacy services.
Resident 77 remained, by her own medical record's account, severely cognitively impaired, diagnosed with a condition that causes the brain to malfunction when the body's systems stop working correctly, and prescribed a drug meant to keep her from wasting away. For at least three days across two months, that drug wasn't there. Her doctor didn't know.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arbor Grove Village from 2026-04-24 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
ARBOR GROVE VILLAGE in GREENSBURG, IN was cited for violations during a health inspection on April 24, 2026.
That finding was one of two medication failures federal inspectors documented during an April 2026 inspection of the Greensburg nursing facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.