Alpha Home - A Waters Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 2640 Cold Spring Rd, Indianapolis, Indiana 46222
- CMS Provider Number
- 155717
- Inspections on file
- 38
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Alpha Home - A Waters Community during CMS and state inspections, most recent first.
A resident who was totally dependent on staff and at high risk for pressure ulcers developed a stage II coccyx wound that progressed to an unstageable ulcer, requiring hospitalization and surgical debridement. The facility failed to document or implement preventive interventions such as regular turning, incontinence care, and use of barrier creams, and did not promptly identify or address the wound, resulting in actual harm.
A resident with a history of stroke, aphasia, and high fall risk fell out of bed while being cared for by a newly hired CNA working alone, despite requiring extensive assistance. The care plan lacked individualized fall prevention interventions and was not updated after the incident. Required 72-hour post-fall assessments and care plan revisions were not completed, contrary to facility policy.
A treatment cart containing biologicals, insulin, blood glucose testing supplies, and unidentified pills was found unlocked and unattended near the nurse's station and dining area. The cart's top drawer was open, exposing medications and supplies, while several residents and a visitor were nearby. An LPN responsible for the cart was out of sight, and later admitted to forgetting to secure it as required by facility policy.
A resident with a history of stroke and chronic pain was injured when he slid out of his wheelchair on a facility bus due to improper securing. The lap belt was not installed, and an incorrect cross-belt was used. The bus driver and maintenance director lacked specific training on the new bus equipment, leading to the incident.
The facility did not ensure Resident Council grievances were addressed and reported back for review, affecting four residents. Despite multiple meetings where residents requested more outings and raised care concerns, no responses were documented. Interviews confirmed that residents often did not receive timely feedback, and the Activity Director acknowledged the lapse in the process.
The facility inaccurately coded the MDS for several residents, leading to discrepancies in medication and PASRR Level II requirements. A resident was incorrectly listed as taking an anticoagulant instead of an antiplatelet, while another's need for PASRR Level II was not reflected. Interviews confirmed these errors, and no specific policy for MDS accuracy was in place.
The facility failed to date opened medications on a treatment and a medication cart, including insulin pens and other medications, as observed with a QMA. The facility's policy on medication storage did not address the requirement to date medications when opened.
A resident expressed dissatisfaction with her long facial hair and requested assistance with shaving, which was not promptly addressed by the facility. Despite her care plan indicating a need for staff assistance with ADLs, her preference for a specific staff member to assist was not initially documented or honored, leading to a delay in addressing her grooming needs.
The facility failed to develop comprehensive care plans for two residents, one with ESRD and another with sleep difficulties, leading to deficiencies in addressing their specific medical needs. The care plans did not initially include necessary details related to dialysis and melatonin use, respectively, despite facility policy requirements.
The facility failed to update care plans for two residents. One resident, with depressive and anxiety disorders, had a care plan that did not reflect her refusal of gradual dose reductions for medications. Another resident, with dementia and major depressive disorder, had a care plan indicating a risk for mood decline but did not have an antidepressant in her medication regimen. These issues were identified during record reviews and interviews with the DON and RCS.
A resident with a history of stroke and other medical conditions fell from a wheelchair on a facility bus and was moved back into the chair by staff without a medical assessment. The resident was not properly secured in the bus, and the facility's policy requiring immediate nurse assessment before moving a resident after a fall was not followed. This led to a deficiency in providing appropriate care.
A facility failed to provide necessary care to a resident to prevent worsening contractures in her hand and wrist. Despite therapy recommendations for passive range of motion (PROM) and palm protector use, these were not documented or implemented in her care plan. Observations showed the resident's hand and wrist were contracted without a splint or palm protector, and the contracture angle increased slightly. The Director of Nursing acknowledged the lack of a policy for range of motion treatments, expecting staff to follow therapy recommendations.
A facility failed to document a resident's blood pressure and pulse before administering metoprolol, an antihypertensive medication, as required by the prescription. The resident's care plan included monitoring blood pressure according to the medical doctor's order or facility policy, but the medication administration records for two months lacked this documentation. The facility's policy required vital sign monitoring before administering medications dependent on such measures.
The facility failed to document adequate justification for declining pharmacy recommendations to reduce psychotropic medications for two residents. One resident, with multiple psychiatric diagnoses, had no documented symptoms to support the physician's decision to decline a medication reduction. Another resident's medical record lacked behavior monitoring and non-pharmacological interventions, despite recommendations for gradual dose reduction. The facility's Director of Nursing acknowledged the need for better documentation and behavior monitoring.
A resident with a history of supraventricular tachycardia and chronic respiratory failure experienced left mid-foot pain after an incident with a Hoyer lift. An NP ordered a three-view x-ray to rule out acute injury, but the x-ray was delayed, and no results were initially available in the resident's record. The resident reported ongoing pain and difficulty moving, and the DON confirmed the x-ray was only conducted later, indicating a lapse in timely care.
A facility failed to properly sanitize a blood glucometer used for a resident. An LPN performed a blood sugar test and cleaned the glucometer with a Sani-wipe, allowing it to dry for 5 minutes. However, the facility's policy required a more thorough cleaning process, including wiping the glucometer with a towelette three times horizontally and vertically, and ensuring it remained wet for 2 minutes with a Super Sani cloth wipe. The LPN did not adhere to this procedure, resulting in a deficiency.
A resident with diabetes, chronic kidney disease, and chronic hepatitis did not receive requested influenza, pneumonia, and COVID-19 vaccinations. Despite signed consents for pneumococcal and COVID-19 vaccines, the facility failed to administer them due to unavailability and preference for a clinic session. The influenza vaccine was not documented for acceptance or declination.
A resident with a tracheostomy was admitted to the facility without the necessary physician's orders for tracheostomy care, oxygen, and suctioning. Despite the setup of respiratory equipment by a supply company, the facility did not have a care plan or orders in place until weeks later. The DON acknowledged the oversight, which was contrary to the facility's policy requiring immediate care orders upon admission.
Failure to Prevent and Manage Pressure Ulcer Resulting in Harm
Penalty
Summary
A resident with a history of nontraumatic intracerebral hemorrhage, aphasia, dysphagia, and total dependence for activities of daily living was admitted to the facility without any skin impairment. Upon admission, assessments identified the resident as high risk for pressure ulcers due to immobility, incontinence, and comorbidities. The care plan included interventions such as keeping the resident clean and dry, performing peri care after each incontinent episode, and using emollients and barrier creams as recommended by the wound nurse practitioner. However, the clinical record lacked documentation that these preventive measures were implemented, including the use of emollients, barrier creams, regular turning and repositioning, and off-loading. Within two weeks of admission, the resident developed a stage II pressure ulcer on the coccyx, which rapidly progressed to an unstageable wound requiring surgical debridement and hospitalization. Documentation was missing regarding the identification of the wound, notification of the physician or family, and initiation of appropriate nursing interventions when the wound was first observed. Preventive skin care orders were not documented in the Medication Administration Records, and there was no evidence that a personalized skin care plan was developed or implemented prior to the development of the pressure ulcer. Interviews with staff and review of facility policy revealed that the resident was dependent on staff for all care, including incontinence management and repositioning, but there was no documentation to confirm these interventions were consistently provided. The facility's policy required prompt identification of at-risk residents and immediate implementation of specific interventions, but the record did not show that these steps were taken before the pressure ulcer developed. The lack of preventive care and timely intervention resulted in actual harm to the resident, who required hospitalization and advanced wound care.
Failure to Individualize and Implement Fall Prevention Interventions and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that fall prevention interventions were individualized and implemented for a resident with significant medical needs, and did not complete required fall follow-up assessments and care plan updates after a fall incident. The resident, who had a history of stroke, aphasia, dysphagia, pressure ulcer, and right-sided weakness, was identified as high risk for falls and required extensive assistance from two or more staff for bed mobility and transfers. Despite these needs, the resident fell out of bed while being cared for by a newly hired CNA working alone during a check and change. The care plan at the time lacked resident-specific interventions and was not updated following the fall. Additionally, the clinical record did not contain documentation of 72-hour post-fall assessments with vital signs, a Post Fall Review assessment, or updates to the care plan as required by facility policy. Interviews with the DON and LPN confirmed that the fall occurred during care provided by a single aide, and that the care plan had not been appropriately individualized or revised after the incident. The facility's policy required documentation and investigation after falls, as well as the implementation of new care plan interventions, but these steps were not completed for this resident.
Unattended and Unlocked Treatment Cart with Exposed Medications and Supplies
Penalty
Summary
During a random observation, a treatment cart containing tubes and bottles of biologicals, including medications for skin conditions and wounds, was found unlocked and unattended near the nurse's station, outside the main dining room, and close to the entry of a hallway. The top drawer of the cart was open, exposing insulin, blood glucose testing supplies, a box of exposed lancets, bottles of blood glucose strips, packaged dressings, and alcohol pads. Additionally, a plastic medication cup with unidentified pills and capsules was left unsecured on top of the cart. Eight residents were observed in the main dining room within view of the cart, and one resident was standing beside it. A visitor was also present near the unsecured cart, conversing with the resident for over two minutes while the cart remained unattended. The LPN responsible for the cart was inside the nurse's station, approximately twelve feet away and out of sight of the treatment cart. Upon noticing the situation, the LPN quickly secured the cart by closing the drawer, locking it, and moving it inside the nurse's station. The LPN later acknowledged that the cart should not have been left unlocked but stated she became distracted by another resident and forgot about it. Facility policy requires that medication carts and supplies be locked or attended by authorized personnel at all times, and that external medications be kept in a treatment cart or a separate, labeled drawer.
Resident Injury Due to Improper Securing on Facility Bus
Penalty
Summary
The facility failed to prevent potential accidents when transportation staff were not adequately trained on new bus equipment, leading to an incident where a resident was not properly secured with a safety lap belt. This resulted in the resident sliding out of his wheelchair during transit on the facility bus, causing him to sustain a fracture of the L1 vertebra with a 20% height loss. The resident, who had a history of stroke, left-sided weakness, vascular dementia, and chronic pain, was on his way to a dental appointment when the incident occurred. Upon review, it was found that the resident was not properly secured into the bus prior to departure. The lap belt, which was necessary for securing the resident, was still in its original packaging and had not been installed. Instead, an incorrect cross-belt was used, which was buckled into the adjacent seat's clip across the aisle. This improper securing method contributed to the resident's fall from the wheelchair. The investigation revealed that the bus driver and maintenance director had not received job-specific orientation or training for transportation safety on the new facility bus. The new bus had been delivered earlier in the year, and basic functions were reviewed with the administrator and a regional consultant, but no formal training was documented for the staff responsible for resident transport.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to ensure that grievances raised by the Resident Council were followed up on and reported back to the council for review and approval. This deficiency was identified through interviews and record reviews, revealing that the facility did not document responses to requests and grievances made by the Resident Council. Specifically, during meetings held on various dates, residents expressed desires for more outings and raised concerns about general nursing care, including call light response times and staff behavior. However, there was no documentation of any responses to these concerns. Interviews with residents and the Activity Director (AD) confirmed that residents often did not receive timely responses to their grievances. The AD acknowledged that the process should involve submitting response forms to department heads to ensure residents receive feedback at subsequent meetings. The facility's policy on Resident Council participation emphasizes the importance of timely responses to concerns, yet this process was not adhered to, as evidenced by the lack of documented responses to the council's minutes.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for five residents, leading to discrepancies in their medical records. Resident 9 was incorrectly coded as taking an anticoagulant when she was prescribed aspirin, an antiplatelet. Similarly, Resident 12's MDS inaccurately indicated she was on an anticoagulant, despite her prescriptions for aspirin and Plavix, both antiplatelet medications. Resident 11's MDS also incorrectly listed an anticoagulant instead of the antiplatelet aspirin he was taking. These inaccuracies in medication coding could potentially affect the residents' care plans and risk assessments. Additionally, Resident 47's MDS failed to reflect the requirement for a PASRR Level II, despite documentation indicating the necessity due to his mental health conditions. Resident 33's MDS inaccurately recorded the use of an anticoagulant, which was not supported by her medical orders. Interviews with the Director of Nursing and the Regional Nurse Consultant confirmed these discrepancies, and it was noted that there was no specific policy for ensuring MDS accuracy, with reliance placed on the RAI manual.
Failure to Date Opened Medications
Penalty
Summary
The facility failed to date medications when opened, as observed during a survey. On the 300-hall treatment cart, a Lantus pen and a Humalog pen, both used for diabetes treatment, were found without dates indicating when they were opened. Additionally, on the 300-hall medication cart, a Flonase bottle and a bottle of ear drops were also found without opening dates. These observations were made with a Qualified Medication Assistant (QMA) present. The facility's policy on medication storage, provided by the Regional Nurse Consultant, did not include information regarding the requirement to date medications when opened.
Failure to Ensure Resident Dignity in Grooming Needs
Penalty
Summary
The facility failed to ensure dignity for a female resident, identified as Resident 33, who expressed dissatisfaction with her long facial hair and requested assistance with shaving. Despite her request, the facility did not promptly address her need for assistance. Resident 33, who had a self-care deficit and required staff assistance with activities of daily living (ADLs), was observed with long facial hair on multiple occasions. She communicated her desire to have the facial hair removed to the staff, but no action was taken to fulfill her request in a timely manner. Resident 33's care plan indicated she had late loss ADLs and required staff assistance, yet her preference for a specific staff member to assist with shaving was not initially documented or honored. The Director of Nursing (DON) later discovered Resident 33's preference for a particular staff member, Qualified Medication Assistant (QMA) 16, to perform the task. However, QMA 16's schedule did not align with the times Resident 33 requested assistance, leading to a delay in addressing her grooming needs. This oversight resulted in a failure to honor the resident's right to dignity and respect, as outlined in the facility's policy on resident rights.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific medical needs. Resident 47, diagnosed with end-stage renal disease (ESRD), dementia, hypertension, and age-related physical debility, did not have a care plan that addressed his nutritional needs related to ESRD with dialysis. Although a care plan was eventually provided, it was not initially included in his medical record, indicating a lapse in comprehensive care planning. Similarly, Resident 12, who had diagnoses including dementia, chronic kidney disease, major depressive disorder, and anxiety, was prescribed melatonin for difficulty sleeping. However, her care plan did not address her sleep difficulties or the use of melatonin. This oversight highlights a failure to incorporate all aspects of her care needs into the comprehensive care plan. The facility's policy requires that comprehensive care plans be finalized within seven days of completing the full comprehensive minimum data set (MDS) assessments, but this was not adhered to in these cases.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plans with changes in resident care for two residents. Resident 25, diagnosed with depressive disorder, generalized anxiety disorder, and a history of opioid abuse, had a care plan addressing the use of medications for behavior management, including Buspar, trazodone, duloxetine, and mirtazapine. However, the care plan did not reflect her refusal to undergo gradual dose reductions (GDR) as per her preference. Resident 12, diagnosed with dementia, major depressive disorder, and insomnia, had a care plan indicating a risk for mood decline related to her major depression diagnosis. Despite this, her medication regimen did not include an antidepressant, which was inconsistent with her care plan. These deficiencies were identified during record reviews and interviews with the Director of Nursing and Regional Nurse Consultant.
Failure to Ensure Medical Assessment Before Moving Resident After Fall
Penalty
Summary
The facility failed to ensure that a resident who experienced a fall was not moved until after a medical assessment was completed. The incident involved a long-term care resident with a history of stroke, weakness/paralysis on the left side, vascular dementia, muscle wasting and atrophy, chronic pain syndrome, and a wedge compression fracture of the L1 vertebra. The resident fell while being transported on the facility bus to a dental appointment, sliding out of his wheelchair and landing on the floor. He complained of pain in his left shoulder/elbow and mentioned hitting his head on the wheelchair. Upon the resident's return to the facility, neurological checks were performed and were within normal limits. However, the resident later exhibited symptoms of nausea and vomiting, leading to a hospital evaluation where an acute to subacute compression fracture of the L1 vertebra was discovered. The investigation revealed that the resident had not been properly secured in the bus prior to departure. The bus driver and maintenance director moved the resident back into his wheelchair without waiting for a medical assessment, contrary to facility policy. The facility's policy requires that any incident or accident, including falls, be reported immediately to a nurse or designated person in charge, and that an immediate assessment be completed by a nurse to determine if the resident can be moved. The Director of Nursing indicated that the bus driver and maintenance director should have called for a medical professional's assessment before moving the resident, as moving him could have worsened any injuries. The facility's failure to adhere to this policy resulted in a deficiency in providing appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Prevent Worsening of Contractures in Resident
Penalty
Summary
The facility failed to provide appropriate care to a resident, identified as Resident 35, to prevent the worsening of contractures in her hand and wrist. Observations on multiple occasions revealed that Resident 35's right hand was contracted into a fist, and her wrist was contracted upward, without the use of a splint or palm protector. Despite recommendations from an Occupational Therapy (OT) referral summary for continued assistance with hand hygiene, passive range of motion (PROM), and palm protector wear to prevent skin breakdown and increase joint mobility, these measures were not documented or implemented in her care plan. Resident 35's medical record lacked documentation of PROM services and an order to wear a palm protector. The Director of Rehab confirmed that although Resident 35 had completed therapy after meeting a goal of decreasing her contracture, the angle of her contracture had increased slightly. The Director of Nursing indicated there was no policy for range of motion treatments and services, but expected nursing staff to follow therapy recommendations. This oversight resulted in a deficiency as the facility did not ensure the resident received necessary treatments and services to prevent the worsening of her condition.
Failure to Monitor Vital Signs Before Administering Antihypertensive Medication
Penalty
Summary
The facility failed to adhere to the prescribed medication administration protocol for a resident diagnosed with hypertension. The resident was prescribed metoprolol, an antihypertensive medication, with specific instructions to hold the medication if the systolic blood pressure was less than 100 or the pulse was less than 60. However, a review of the medication administration records for August and September 2024 revealed a lack of documentation of the resident's blood pressure and pulse prior to administering the medication. This oversight occurred despite the resident's care plan, which included monitoring blood pressure as per the medical doctor's order or facility policy. The facility's policy on drug administration emphasized the necessity of performing vital sign monitoring before administering medications dependent on such measures.
Inadequate Documentation for Declining Psychotropic Medication Reduction
Penalty
Summary
The facility failed to ensure adequate documentation and justification for declining pharmacy recommendations to reduce psychotropic medications for two residents. Resident 34, diagnosed with dementia, schizoaffective disorder, bipolar type, and anxiety, was scheduled for a trial reduction of an antianxiety medication. The physician declined the recommendation, citing symptoms, but there was no documentation of symptoms in the resident's behavior monitoring records or nursing progress notes. The Director of Nursing acknowledged that there were no symptoms of increased or worsening anxiety, and the recommendation should have been accepted or a different reason provided for declining it. Similarly, Resident 9, with diagnoses including schizoaffective disorder, bipolar type, delusional disorder, and major depressive disorder, was prescribed multiple psychotropic medications. The pharmacist recommended a gradual dose reduction, but the request was declined due to the resident reportedly remaining symptomatic. However, the medical record lacked documentation of daily behavior monitoring or symptoms. The care plans for Resident 9 did not include non-pharmacological interventions to address identified behaviors. The Director of Nursing and Regional Nurse Consultant noted the need for detailed reasons for not performing a gradual dose reduction and added behavior monitoring to the resident's medical record.
Failure to Provide Timely X-Ray Services
Penalty
Summary
The facility failed to ensure timely x-ray services for a resident who was reviewed for x-rays. The resident, who had a history of supraventricular tachycardia, chronic respiratory failure, and age-related debility, complained of left mid-foot pain after an incident involving a Hoyer lift pad. A Nurse Practitioner ordered a three-view x-ray of the resident's left foot to rule out acute injury and prescribed acetaminophen for pain management. Despite the order, there were no x-ray results available in the resident's record. The resident reported ongoing soreness in her left foot and difficulty pushing herself up in bed, indicating that the x-ray had not been performed. The Director of Nursing later confirmed that the x-ray was conducted the night before the interview, indicating a delay in providing the necessary diagnostic service. The facility's policy on resident rights emphasizes the importance of enhancing residents' well-being and quality of life, which was not upheld in this instance.
Improper Sanitization of Glucometer
Penalty
Summary
The facility failed to properly sanitize a blood glucometer used for Resident 103. During an observation, an LPN performed a blood sugar test for Resident 103 using a glucometer that was stored on the treatment cart. The LPN indicated that the glucometer was clean from its previous use and proceeded with the blood sugar test. After completing the test, the LPN used a Sani-wipe to clean the monitor and placed it on a Kleenex to dry, stating it would sit for 5 minutes before being returned to its box. However, the facility's policy required the glucometer to be wiped with a towelette three times horizontally and vertically, using a second towelette to ensure it remained wet for 2 minutes with a Super Sani cloth wipe. The LPN did not follow this procedure, leading to a deficiency in infection prevention and control.
Failure to Administer Requested Vaccinations
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 102, received the influenza, pneumonia, and COVID-19 vaccinations as requested. Upon review of Resident 102's medical records, it was found that the sections for these immunizations were left blank. The resident had signed consents for the pneumococcal and COVID-19 vaccines, dated 9/6/24, but there was no documentation for the acceptance or declination of the influenza vaccine. The Director of Nursing (DON) indicated that the pneumonia vaccine was not administered upon admission due to its unavailability and preferred to administer all vaccines during a clinic session. Resident 102's medical history includes diabetes mellitus, chronic kidney disease, and chronic hepatitis, which are significant conditions that necessitate timely vaccinations. Despite the resident's consent and the facility's provision of CDC vaccination information sheets upon admission, the facility did not follow through with the administration of the requested vaccines. This oversight was identified during a review and interview process, highlighting a lapse in the facility's vaccination protocol for residents who have expressed their desire to receive these immunizations.
Failure to Obtain Physician Orders for Tracheostomy Care
Penalty
Summary
The facility failed to ensure that a resident with a tracheostomy had the necessary physician's orders for tracheostomy care, oxygen, oxygen humidity, suctioning, and to maintain oxygen saturation levels above 90%. This deficiency was identified for one of the two residents reviewed with a tracheostomy, referred to as Resident B. Resident B was admitted to the facility with multiple complex medical conditions, including acute respiratory failure with hypoxia, pulmonary embolism, and a history of kidney transplant rejection, among others. Upon admission, the respiratory care supply company set up the necessary respiratory equipment for Resident B, including an Airvo system, oxygen mask, and suctioning equipment. However, the facility did not have a care plan or physician's orders for the tracheostomy care and oxygen management until several weeks after the resident's admission. The Director of Nursing acknowledged that these orders were overlooked and should have been entered into the resident's medical record when the equipment was set up and before the resident's admission. The facility's policy requires that physician orders for a resident's immediate care be in place at the time of admission. This includes orders for dietary needs, medications, and routine care to maintain or improve the resident's functional abilities. Despite this policy, the necessary orders for Resident B's respiratory care were not obtained or implemented in a timely manner, leading to the identified deficiency.
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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