Arbor Grove Village: Medication Safety Failures - IN
That was one of two medication failures documented during an April 2026 inspection at Arbor Grove Village, a nursing facility in Greensburg, Indiana. The inspection covered 22 residents for pharmacy services. Two had problems. Both involved the same nurse.
On the morning of April 23, Registered Nurse 11 was in Resident 82's room completing a treatment. Licensed Practical Nurse 12, identified in the inspection report as a nurse in training, had already prepared two pink antacid tablets and brought them to the room, setting them in a cup on the resident's over-the-bed table. RN 11 told her to wait until the treatment was finished before giving the medications. LPN 12 gave them anyway.
RN 11 described it that way herself during an interview with inspectors later that morning. She said the standard practice was for the nurse who prepared a medication to be the one who administered it. LPN 12 had done the preparing. RN 11 had not been present when the tablets were given. The facility's own medication administration policy, revised in April 2025, stated that staff should observe residents taking their medications. The observation did not happen.
The second finding was more serious and had been going on for days before anyone noticed.
Resident 77 was severely cognitively impaired, according to a Significant Change assessment completed in March 2026. The resident's diagnoses included metabolic encephalopathy, a condition in which underlying systemic illness disrupts normal brain function, and adult failure to thrive. For that last diagnosis, the resident had been prescribed Megestrol Suspension 400 mg twice daily.
The medication administration records for February and March 2026 showed the resident went without it three times in two days. On the evening of February 25, the dose was not available. On the morning and evening of February 26, it was still not available. The records listed the reason each time as the medication being unavailable.
A separate medication, Sodium Chloride 1,000 mg prescribed three times daily, was also missing from the cart. The resident did not receive it on the afternoon of March 2, the evening of March 2, or the morning of March 3.
Six missed doses across two medications. The clinical record contained no documentation that a physician had been notified about any of them.
RN 11, interviewed again on April 24, explained the facility's process for handling medication shortages. If a drug wasn't in the medication cart, staff were supposed to check the emergency drug kit. If it wasn't there either, they could order it STAT, which she said would bring delivery within two to four hours. Regular medication deliveries arrived daily between 6 and 8 in the morning. If a medication couldn't be obtained, she said, the physician should be notified, and staff should document in the electronic medication record or progress notes that the medication was unavailable and that the doctor had been called.
None of that documentation existed for Resident 77.
The facility's policy on medication shortages, revised in August 2024 and provided to inspectors by the Regional Director of Clinical Services, directed staff to immediately contact the pharmacy when a shortage was discovered at the time of medication administration. The records showed the shortage was discovered, documented as unavailable, and left there.
Megestrol is an appetite stimulant prescribed specifically to address weight loss and failure to thrive in adults who are not eating enough to sustain themselves. Resident 77 was already diagnosed with the condition the drug was meant to treat. The resident was also severely cognitively impaired, meaning they could not have advocated for themselves or asked why the medication hadn't arrived.
Inspectors rated both violations at the level of minimal harm or potential for actual harm. The findings were cited under Indiana Administrative Code governing pharmacy services in long-term care facilities.
The physician was never called.
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 21, 2026 · Our methodology
ARBOR GROVE VILLAGE in GREENSBURG, IN was cited for violations during a health inspection on April 24, 2026.
That was one of two medication failures documented during an April 2026 inspection at Arbor Grove Village, a nursing facility in Greensburg, Indiana.
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.