Castleton Health Care Center
CASTLETON HEALTH CARE CENTER in INDIANAPOLIS, IN — inspection on April 27, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
p.m.-HumaLOG KwikPen (short-acting insulin) 100 UNIT/ML strength inject subcutaneously (under
and 4-18-26 at 8:00 a.m. and 12:00 p.m., and 4-19-26 at 8:00 a.m. 4.The clinical record of Resident E
psychoses, anxiety, depression, type 2 diabetes, polyosteoarthritis (degenerative disease where osteoarthritis affects five or more joints) and polyneuropathy (damage to multiple nerves throughout the body).A review of her medication administration record (MAR) for April, 2026, indicated multiple physician-ordered medications were not documented as administered as identified by the administration block, was blank, which signifies the medications were not administered.
Corresponding documentation in the MAR or the progress notes failed to identify the reason the medications were not administered.
The undocumented medications were as follows:-Buspar (an anti-anxiety medication) 15 milligrams (mg) three times a day for anxiety was not administered on 4-1-26 at 5:00 p.m.-Eliquis (an anticoagulant medication) 2.5 mg twice daily for anticoagulation therapy was not administered on 4-1-26 at 6:00 p.m.-Lyrica (an anticonvulsant and pain medication) 75 mg twice daily for pain was not administered on 4-1-26 at 6:00 p.m.-Ropinirole (a dopamine antagonist used in the treatment of restless leg syndrome) 1 mg twice daily for restless leg syndrome was not administered on 4-1-26 at 6:00 p.m.-Quetiapine Fumarate (an anti-psychotic medication) 50 mg at bedtime for depression was not administered on 4-1-26 at 9:00 p.m.-Famotidine (a histamine receptor antagonist used to decrease stomach acid production) 10 mg at bedtime for stomach discomfort was not administered on 4-1-26 at 9:00 p.m. On 4-27-26 at 3:16 p.m., the Director of Nursing provided a copy of an undated policy entitled, Medication Error Reporting.
This policy indicated its purpose as To develop policies and procedures for proper distribution of resident's medications. It indicated, The facility Administrator shall ensure that all nursing employees who distribute medication [sic] are oriented and comply with the facility's medication distribution policy.
If a medication error should occur, the nursing employee making the medication error, or if different, the Nurse finding the medication error shall complete a medication report. A Medication Error Report shall be completed whenever it is indicated that there is a medication error, treatment error or documentation error.
The form shall be initiated by the Licensed Nurse who discovered the error.
The Director of Nursing or Assistant Director of Nursing shall be notified .shall direct the investigation, notification of the physician and family, and appropriate follow-up.
The completed Medication Error Report shall be signed by the Director of Nursing and forwarded to the Administrator .The Administrator and Director of Nursing shall analyze the occurrence and determine the appropriate counseling . On 4-27-26 at 3:16 p.m., the Director of Nursing provided an undated copy of an educational training entitled, Medication Not Available in the Medication Cart.
This training information indicated, When a prescribed medication is not available in the medication cart, prompt action is essential to ensure resident safety, maintain continuity of care and comply with regulatory requirements.
Immediate Steps: Verify the order .Check the Emergency Drug Kit .Contact the Pharmacy .Notify the Provider .Notify the Resident and Family/Responsible Party .Document thoroughly in the medical record, including: medication name, dose and scheduled administration time, steps taken to locate the medication, pharmacy contact, including date, time and representative spoke to, provider notification and any orders received, family/responsible notification, resident assessment and any observed effects, follow-up actions taken .follow facility policies and procedures at all times, report recurring medication availability issues to nursing leadership. On 4-26-26 at 12:26 p.m., the Executive Director and Director of Nursing were electronically requested to provide copies of the facility's policies and procedures for medication and treatment administration documentation. As of exit from the survey on 4-27-26, this information had not been provided.
This citation relates to Intakes 2975067 and 2981085. 410 IAC (Indiana Administrative Code 3.1-25(b)(3)410 IAC (Indiana Administrative Code 3.1-25(b)(9)
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.