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F0677
D

Failure to Provide Safe and Respectful ADL Assistance

Indianapolis, Indiana Survey Completed on 09-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide safe and comfortable assistance with activities of daily living (ADLs) for two residents. For one resident with dementia, Alzheimer's disease, and mobility difficulties, a Qualified Medication Aide (QMA) transported her from the shower room to her bed by having her sit on a rollator walker and pushing her, rather than using a gait belt as required by facility policy. The QMA then attempted to transfer the resident to bed by lifting her under the armpits, which was observed by an LPN who intervened due to the rough handling. The QMA admitted to not using a gait belt and acknowledged the resident's refusal to stand, but proceeded with the transfer regardless of proper technique. For another resident with Parkinson's disease, vascular dementia, osteoporosis, and a recent pathological ankle fracture, care plans indicated the need for two-person assistance with bed mobility and transfers due to pain and risk of injury. During incontinence care, a QMA was observed by a CNA to be providing care alone, with the resident crying out in pain and being held in a position that caused distress. The CNA intervened and reported the incident to nursing staff. Both incidents were found to be in violation of facility policy and resident rights, as staff failed to follow established procedures for safe and respectful ADL care.

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