Allisonville Meadows
Inspection history, citations, penalties and survey trends for this long-term care facility in Fishers, Indiana.
- Location
- 10312 Allisonville Rd, Fishers, Indiana 46038
- CMS Provider Number
- 155786
- Inspections on file
- 36
- Latest survey
- March 31, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Allisonville Meadows during CMS and state inspections, most recent first.
A facility failed to notify a physician promptly after a resident's fall, resulting in delayed treatment for a humerus fracture. Additionally, another resident's abnormal lab results indicating acute kidney injury were not communicated in a timely manner, delaying necessary treatment. These deficiencies highlight lapses in communication and adherence to protocols.
A resident with a history of falls and severe cognitive impairment fell and was not assessed by a licensed nurse, leading to a delay in treatment for a fractured humerus. Facility staff failed to document the fall or notify the physician, resulting in the resident self-reporting the incident the following day. The lack of communication and adherence to the fall management policy contributed to the deficiency.
The facility failed to provide adequate ADL care for several residents, including improper hair washing, positioning, and incontinence management. A resident with a traumatic brain injury reported unwashed hair and improper bed positioning. Another resident with Alzheimer's was left in urine for extended periods, and a resident with COPD experienced delays in care and double briefing. Additionally, a resident with dementia was not checked for incontinence as required.
The facility failed to ensure proper hand hygiene and infection control practices, as observed in the care of several residents. A CNA did not perform hand hygiene during incontinent care for a resident with a history of traumatic brain injury and diabetes. Another CNA failed to perform hand hygiene during catheter care for a cognitively impaired resident at risk of MDRO transmission. Additionally, staff did not perform hand hygiene during coffee service, and medication carts were not cleaned after being touched by residents, indicating non-compliance with the facility's hand hygiene policy.
A facility failed to honor a resident's choice regarding her bedtime. The resident, who is cognitively intact, preferred to be put to bed between 7:15 p.m. and 7:30 p.m., but reported being put to bed much later on some days. The Unit Manager confirmed that the resident's care plan did not include her bedtime preferences, despite documentation indicating its importance. A CNA acknowledged the resident's preference but noted it was not always followed due to other situations.
A facility failed to document urinary output for a resident with an indwelling catheter as ordered. The resident, who was severely cognitively impaired, had a care plan requiring documentation of urinary output every shift, but records were incomplete or missing on several occasions. The facility's policy required documentation in milliliters, but output was recorded qualitatively instead.
The facility failed to provide timely medications for two residents. One resident, admitted with pneumonia, did not receive several prescribed medications due to pharmacy order issues and lack of follow-up by staff. Another resident with chronic pain did not receive a buprenorphine patch as ordered, as it was not re-ordered in time and was unavailable in the emergency drug kit.
A resident in an LTC facility experienced a significant medication error when nursing staff failed to administer fentanyl patches according to the physician's order and professional standards. The resident, who was cognitively impaired, had two patches applied simultaneously, leading to an overdose and hospitalization. The facility's failure to remove old patches and adhere to the prescribed schedule resulted in the resident's adverse reaction.
A resident with Alzheimer's and hypertension fell and sustained a hip fracture, but the family was not notified until the next day. The fall was not documented immediately, and the resident was found in pain the following day, leading to a hospital transfer.
A resident with Alzheimer's and other conditions was not provided with hipsters as part of their fall prevention plan, despite a physician's order and facility policy. Observations showed the resident without hipsters, and an LPN was unaware of their requirement or location.
A facility failed to document and manage a resident's behavioral health needs, who exhibited problematic behaviors such as yelling and inappropriate comments. Despite care plans including interventions like providing care in pairs and mental health services, these were not consistently implemented or evaluated. The facility's lack of documentation and evaluation led to ongoing issues with the resident's adjustment to LTC.
A resident with a urinary catheter experienced frequent leakage, resulting in a strong urine odor in the hallway. Despite the resident's care plan to manage catheter care, the staff reportedly did not lock the tubing correctly, causing leakage. Housekeeping staff mopped urine from the floor multiple times a week, but the DON and ED were unaware of the issue.
A facility failed to maintain accurate records for controlled medications for a hospice resident with multiple diagnoses, including hypertension and respiratory failure. The resident was prescribed lorazepam with specific administration instructions, but records showed incorrect dosages were administered. An interview with the DON revealed discrepancies in medication documentation, indicating a failure in the facility's medication administration and record-keeping processes.
The facility failed to ensure proper nail trimming and hand hygiene for three residents requiring upper extremity devices. Observations revealed long nails and unclean hands, with the FDNS confirming the need for better adherence to care plans and procedures.
Failure to Notify Physician of Fall and Lab Results
Penalty
Summary
The facility failed to ensure timely notification of a fall and subsequent injury for Resident D, who was moderately cognitively impaired and diagnosed with Alzheimer's disease. On the morning following the fall, Resident D reported shoulder pain to a nurse, who observed bruising and swelling but was not aware of the fall until later. The resident had self-reported the fall to staff the previous evening, but the nurse on duty was not informed, resulting in a delay in treatment for a left humerus fracture. The resident was eventually transferred to the emergency room for evaluation and treatment after experiencing significant pain and a fainting spell. Additionally, the facility did not promptly inform a physician of a significant change in laboratory values for Resident B, who had a history of urinary tract infection, diarrhea, and dementia. Despite a physician's order for a basic metabolic panel (BMP) to be conducted, the results indicating elevated creatinine and BUN levels were not communicated to the physician until two days later. This delay in communication resulted in a delay in the initiation of intravenous fluids, which were necessary to address Resident B's acute kidney injury. The facility's failure to adhere to its policies regarding the notification of physicians and timely intervention following significant changes in resident conditions contributed to the deficiencies identified in the report. The lack of immediate communication and assessment following Resident D's fall and the delay in addressing Resident B's abnormal lab results highlight the need for improved staff training and adherence to established protocols.
Failure to Assess and Monitor Resident After Fall
Penalty
Summary
The facility failed to ensure that a resident who had fallen was properly assessed and monitored by a licensed nurse. On the night of the incident, the resident fell and was assisted back to bed by facility staff, including a Qualified Medication Aide and a Certified Nurse Aide, without notifying a licensed nurse. The resident, who was severely cognitively impaired and required substantial assistance with mobility, later reported pain and was found to have a fractured humerus, which required hospitalization. The resident's clinical record indicated a history of falls and a care plan that included various interventions to prevent falls. Despite these measures, the resident fell and was not immediately assessed by a nurse. The following day, the resident self-reported the fall and exhibited signs of pain and injury, including bruising and swelling on the left shoulder and a skin tear on the left elbow. The facility staff failed to document the fall or notify the physician immediately, as required by the facility's fall management policy. Interviews with staff revealed a lack of communication and documentation regarding the fall. Several staff members, including a Licensed Practical Nurse and a Registered Nurse, were unaware of the fall until the resident self-reported it the next day. The resident's representative was also not informed of the fall until they arrived at the facility. The facility's failure to follow its fall management policy and ensure timely assessment and documentation of the fall led to a delay in the resident receiving appropriate medical care.
Deficiencies in ADL Care and Incontinence Management
Penalty
Summary
The facility failed to provide adequate care for several residents, leading to deficiencies in activities of daily living (ADL) care. Resident L, who had a history of traumatic brain injury and diabetes, required assistance with ADLs due to weakness from a recent hospital stay. Despite being cognitively intact, Resident L reported that her hair had not been washed in two weeks, and she felt that incontinence care was lacking. Observations confirmed that her hair was unwashed, and she was improperly positioned in bed, increasing the risk of skin shearing. Resident D, diagnosed with Alzheimer's disease, was moderately cognitively impaired and required assistance with toileting due to various health issues. Despite a care plan indicating the need for incontinence checks every two hours, Resident D's family reported instances where he was left in urine for extended periods. Observations and interviews revealed that staff were not consistently performing the required checks, and documentation of urinary output was infrequent. Resident 20, with chronic obstructive pulmonary disease and moderate cognitive impairment, reported infrequent changes and was under the impression that double briefing was standard care. Observations confirmed delays in response to her requests for assistance, and staff were found to be using double briefs, which was not a standard practice. Similarly, Resident G, who required assistance due to dementia and incontinence, was not checked for incontinence every two hours as required. Family members reported and observations confirmed that staff did not perform regular checks, leading to prolonged periods without necessary care.
Inadequate Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during the provision of care for several residents, leading to potential infection control issues. For Resident L, who has a history of traumatic brain injury and diabetes, a Certified Nurse Aide (CNA) did not perform hand hygiene when changing gloves during incontinent care. The CNA used double gloves, which was not in accordance with the facility's policy, and failed to perform hand hygiene between glove changes, despite Resident L's concerns about the quality of care and risk of urinary tract infection. In another instance, during catheter care for Resident E, who is severely cognitively impaired and at risk of MDRO transmission, a CNA failed to perform hand hygiene after touching high-contact surfaces before handling clean washcloths and providing care. The CNA touched various surfaces, including a doorknob and a bedside table, without changing gloves or performing hand hygiene, which compromised the infection control measures required for Resident E's care. Additionally, during a coffee service, staff members did not perform hand hygiene before and after interacting with residents, and medication carts were not cleaned after being touched by residents. A CNA and a Qualified Medication Aide (QMA) failed to sanitize the medication cart surfaces after residents placed items on them or touched them, which could lead to cross-contamination. These observations indicate a lack of adherence to the facility's hand hygiene policy, which outlines specific moments when hand hygiene should be performed to minimize infection transmission.
Failure to Honor Resident's Bedtime Preference
Penalty
Summary
The facility failed to honor and facilitate a resident's choice regarding her bedtime, as evidenced by the case of Resident 30. Resident 30, who is cognitively intact and has diagnoses including muscle weakness and obesity, expressed a preference to be put to bed between 7:15 p.m. and 7:30 p.m. However, she reported that there were days when she was not put to bed until 9:30 p.m. to 10:00 p.m. An interview with the Unit Manager revealed that Resident 30's care plan did not include her bedtime preferences, although a document titled 'Preferences for Customary Routine and Activities' indicated that choosing her own bedtime was very important to her. A Certified Nurse Aide confirmed that Resident 30 preferred to be put to bed after the evening meal but acknowledged that this did not always occur due to other situations.
Failure to Document Urinary Output for Resident with Catheter
Penalty
Summary
The facility failed to accurately document urinary output for a resident with an indwelling catheter, identified as Resident E. The resident, who was severely cognitively impaired, had a care plan requiring documentation of bowel and urinary output every shift. A physician order also specified that the nurse should record the output every shift. However, the urine output was not documented for two out of three shifts on specific dates and was entirely missing for other dates. When documented, the output was recorded in qualitative terms such as 'Large' or 'Medium' rather than in milliliters as required. During an interview, the facility's Nurse Consultant indicated that urinary output should be documented in milliliters for residents with indwelling catheters. The Director of Nursing provided a Bowel and Bladder Program Policy, which stated that urinary output from indwelling catheters should be documented. The failure to document urinary output as ordered represents a deficiency in the care provided to Resident E.
Medication Availability Deficiency for Two Residents
Penalty
Summary
The facility failed to ensure the timely availability of medications for Resident 182, who was admitted with diagnoses including pneumonia. Upon admission, several physician orders were placed for medications such as finasteride, hydroxyurea, levofloxacin, metoprolol, tamsulosin, and a Trelegy inhaler. However, these medications were not available for administration on multiple occasions as documented in the Medication Administration Record (MAR). The Nurse Consultant indicated that the pharmacy had not received all medication orders upon the resident's admission, and the staff did not follow up promptly to obtain the medications. For Resident 47, who was moderately cognitively impaired and had a diagnosis of chronic pain, the facility failed to administer a buprenorphine patch as ordered on two occasions. The Unit Manager explained that the nurse was supposed to re-order the patch when the last one was placed, but it was not available in the facility's emergency drug kit. The facility's re-ordering policy required medications to be re-ordered when there was a 3-day supply remaining, but this procedure was not followed, resulting in the unavailability of the medication.
Failure to Properly Administer Fentanyl Patches Leads to Resident Overdose
Penalty
Summary
The facility failed to administer a synthetic opioid pain patch in accordance with the physician's order, manufacturer's specifications, or accepted professional standards, resulting in a significant medication error for a resident. The resident, who was cognitively impaired and receiving pain management, was found to have two fentanyl patches applied simultaneously. This error led to a significant change in the resident's consciousness, requiring the emergent administration of an opioid overdose medication and subsequent hospitalization. The clinical record review revealed that the resident was to receive a 75 mcg fentanyl patch every three days for pain, but the patches were applied more frequently than ordered, and previous patches were not removed before new ones were applied. Specifically, the resident received fentanyl patches five times within an eight-day period, and there was no documentation of patch removal or monitoring for changes in the resident's condition. On one occasion, the resident was found unresponsive with two patches in place, necessitating the administration of Narcan and hospitalization. Interviews and documentation indicated that the medication errors were due to nursing staff not adhering to the prescribed schedule and failing to remove old patches. The errors were compounded by a lack of proper documentation and monitoring, which contributed to the resident's adverse reaction. The facility's medication administration procedure policy was not followed, leading to the resident's overdose and subsequent medical intervention.
Failure to Notify Family of Resident's Fall
Penalty
Summary
The facility failed to timely notify a resident's representative of a fall incident involving Resident B, who had a history of Alzheimer's disease and hypertension. On 12/11/24, Resident B was found on the floor in another resident's room, but no injuries were noted at that time. Despite being assessed and showing no immediate signs of pain, Resident B later exhibited pain in her left lower extremity, leading to a physician's order for a STAT X-Ray, which revealed a left femoral neck fracture. The resident was subsequently sent to an acute care hospital for treatment. The deficiency arose because the family member, FM 10, was not informed of the fall until the following day when she visited and noticed Resident B in distress. The facility's investigation revealed that the fall was not documented in the clinical record on the day it occurred, and the family was not notified promptly. Interviews with staff indicated a lack of communication and documentation regarding the fall, which contributed to the delay in notifying the family and addressing Resident B's injury.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to implement care-planned fall interventions for a resident identified as being at risk for falls. The resident, who has diagnoses including Alzheimer's disease, dementia, anxiety, fibromyalgia, and osteoarthritis, was observed multiple times without wearing hipsters, which were part of the prescribed fall prevention measures. A physician's order from July 2024 required the use of hipsters at all times, with nursing staff checking for their use every shift. However, observations on January 2nd and 3rd, 2025, revealed that the resident was not wearing hipsters while sitting in a wheelchair at the nurse's station. When questioned, an LPN was unsure if the resident was supposed to be wearing hipsters and confirmed that the resident was not wearing them upon inspection. The resident's room did not contain hipsters, and the LPN was unaware of their whereabouts, despite knowing the resident had worn them previously. The facility's Fall Management Policy, revised in March 2024, mandates the implementation of resident-centered fall prevention plans for those at risk, but this was not adhered to in the case of this resident.
Failure to Document and Manage Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to adequately document and manage the behavioral health care needs of Resident H, who was admitted with diagnoses including stroke and dementia. Despite being cognitively intact upon admission, Resident H exhibited problematic behaviors such as yelling, cursing, and making inappropriate sexual comments. These behaviors were noted in various nursing and care plan notes, but the facility did not consistently document these incidents or evaluate the effectiveness of the interventions put in place to address them. Resident H's care plans included interventions such as providing care in pairs, encouraging expression of feelings, administering medications, and providing mental health services. However, these interventions were not consistently implemented or evaluated. For instance, there were instances where care was provided by a single staff member, contrary to the care plan's directive to provide care in pairs. Additionally, the facility did not document all behavioral incidents, such as inappropriate sexual comments, in the resident's clinical record. The facility's failure to document and evaluate Resident H's behaviors and the effectiveness of interventions led to ongoing issues with the resident's adjustment to long-term care. Despite discussions during care plan meetings and awareness of the resident's behaviors, the facility did not ensure that staff consistently followed the behavior management policy. This lack of documentation and evaluation contributed to the deficiency identified in the report.
Failure to Maintain Odor-Free Environment Due to Catheter Leakage
Penalty
Summary
The facility failed to maintain an environment free from strong urine odors, affecting one of the three residents reviewed for environmental conditions. Resident J, who has a medical history of neuromuscular dysfunction of the bladder and urinary retention, required an indwelling urinary catheter. The care plan for Resident J, initiated in December 2018, included interventions such as recording urinary output every shift and maintaining a closed catheter system. However, observations on multiple occasions revealed a strong urine odor in the 500 hallway, traced back to Resident J's room. Resident J reported that her urinary catheter frequently leaked onto the floor, suspecting that the staff did not lock the tubing on the bag correctly, leading to the leakage. Housekeeping staff confirmed that they mopped urine from the floor in Resident J's room 2-3 times a week due to leakage from the catheter bag. Despite these occurrences, the Director of Nursing Services and the Executive Director were unaware of the strong urine odor and had not received any concerns regarding the nursing staff's handling of the urinary bag. This deficiency was identified during a complaint investigation related to Complaint IN00446808.
Inaccurate Controlled Medication Records for Hospice Resident
Penalty
Summary
The facility failed to maintain an accurate system of records for controlled medications for a resident receiving hospice services. The resident, who had diagnoses including hypertension, congestive heart failure, and respiratory failure, was prescribed lorazepam, an antianxiety medication, with specific administration instructions. A physician order indicated lorazepam was to be administered at a dosage of one milliliter every three hours, which was later adjusted to every two hours. However, the controlled substances record showed that the medication was administered at a significantly lower dosage of 0.1 milliliters at various times, contrary to the physician's orders. An interview with the Director of Nursing revealed that the lorazepam bottle should have been empty by a certain date, but a new bottle was received and not utilized according to the records. This discrepancy indicated that the documentation on the controlled substances record was inaccurate, as the nursing staff recorded administering a much lower dosage than prescribed. This issue was identified during a review related to a specific complaint, highlighting a failure in the facility's medication administration and record-keeping processes.
Failure to Ensure Proper Nail Trimming and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper nail trimming and hand hygiene for three residents who required upper extremity devices. Resident D, diagnosed with chronic kidney disease and hemiplegia following a stroke, was observed with long nails and a brown flaky substance on his hand, which was only cleaned on shower days. The Float Director of Nursing Services (FDNS) confirmed that the resident's nails needed trimming and that staff should wash the resident's hand before placing the palm protector on it. Resident C, diagnosed with diabetes mellitus, dementia, and chronic kidney disease, was found with long nails despite a care plan indicating the need for nail trimming twice a week. A hospice RN noted a foul smell from the resident's hands and observed maceration between the fingers due to long nails. The FDNS confirmed that the resident's nails needed trimming and that the nursing staff should be responsible for this task. Resident F, diagnosed with dementia and muscle weakness, was observed with long nails with uneven edges and a black substance underneath them. The FDNS confirmed that the resident's nails needed cleaning and trimming. The facility's procedures for splinting device application and fingernail care were not followed, leading to the deficiencies observed in the care of these residents.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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