Aperion Care Greenfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenfield, Indiana.
- Location
- 5430 W Us 40, Greenfield, Indiana 46140
- CMS Provider Number
- 155254
- Inspections on file
- 25
- Latest survey
- September 30, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Aperion Care Greenfield during CMS and state inspections, most recent first.
A resident with anxiety and depression reported abuse by a CNA, including physical and verbal mistreatment. The incident was communicated to the BOM, but due to miscommunication during the Administrator's absence, the report to IDOH was delayed, violating the facility's policy on timely reporting of abuse allegations.
The facility failed to properly dispose of garbage, affecting all residents. During a kitchen tour, it was observed that a dumpster lid was left open, with trash and a glove on the ground nearby. The DM stated she couldn't reach the dumpster door to close it. Observations on subsequent days confirmed the lid remained open, violating the facility's policy requiring covered trash receptacles.
The facility failed to provide fluids at the bedside for seven residents, as required by their policy. Observations showed that residents, including those cognitively intact and impaired, did not have access to fresh ice water. Interviews with staff indicated that water passing was inconsistent and dependent on workload, leading to a deficiency in accommodating residents' needs.
The facility failed to protect residents from physical abuse, with multiple incidents of resident-to-resident altercations involving residents with cognitive impairments and behavioral issues. Despite care plans and staff presence, residents engaged in physical fights, highlighting deficiencies in abuse prevention and intervention measures.
The facility failed to manage soiled linen and PPE disposal properly, leading to deficiencies. Observations showed unbagged soiled linen overflowing from bins in hallways and improper disposal of PPE in uncovered trash receptacles outside rooms of residents under Enhanced Barrier Precautions. Interviews revealed staff were not adhering to the facility's Linen Handling Principles policy, and the Assistant Director of Nursing was unaware of the location of trash receptacle lids.
The facility failed to maintain a homelike environment for two residents. One resident's room had a sticky bathroom floor, an uncovered bedpan, and peeling paint, while another resident's bathroom was cluttered with items on the floor and a removed toilet lid. The Executive Director acknowledged these issues, attributing some to resident behavior.
A facility failed to document that a resident's representative was given a bed hold policy during a hospitalization. The resident, who was cognitively intact and had a stroke diagnosis, was unaware of the policy and did not receive paperwork before a hospital transfer. The Executive Director confirmed the staff could not find the policy, although it was expected to be provided at transfer.
The facility inaccurately encoded MDS information for two residents. One resident with bipolar disorder was incorrectly recorded as not having a PASARR Level II assessment, despite documentation of a serious mental illness. Another resident with chronic obstructive pulmonary disease was inaccurately recorded as not having a terminal prognosis, despite receiving hospice services and having a certification of terminal illness. The MDS Nurse attributed these errors to oversight.
A facility failed to complete a PASARR Level II for a resident diagnosed with schizophrenia before admission. The resident's clinical record showed no PASARR Level II was conducted, despite a Level I screen indicating the need for further evaluation. The Social Service Director cited an oversight due to an influx of residents as the reason for the lapse.
A facility failed to hold scheduled care plan meetings for a resident with dementia and major depressive disorder. Despite completing MDS assessments, there was no documentation of care plan meetings, including a scheduled meeting that lacked verification of occurrence. The resident's family member reported not having any care plan meetings to discuss missed medical appointments, and the Social Services Director confirmed the absence of documentation for these meetings.
The facility failed to follow its activities calendar and provide outdoor activities for residents. A resident reported missing scheduled card games due to lack of cards and was denied outings due to transportation issues. Another resident, who enjoys outdoor activities, noted no outings since February. A third resident experienced a lack of scheduled activities, with no substitute activities provided. Observations confirmed the absence of organized activities, contrary to the facility's policy.
The facility failed to date and document dressing changes for a resident with a forehead wound and did not complete required skin assessments for another resident on antiplatelet therapy. An LPN confirmed the lack of documentation for the dressing, and the DON acknowledged missing skin assessments in the EHR.
A resident with multiple diagnoses, including hemiplegia and major depressive disorder, did not receive timely optometry services despite consenting and having a care plan in place. The facility's Social Services Director confirmed that the resident had not been seen by the optometry provider, contrary to the facility's policy to assist residents in arranging on-site health services.
A facility failed to complete quarterly smoking assessments for a resident with chronic obstructive pulmonary disease who was cognitively intact and a cigarette smoker. The resident's care plan required assessments upon admission, quarterly, and as needed, but staff could not locate the assessments for the past year. The responsibility for these assessments was shared between activities and social services, as per the facility's smoking safety policy.
A cognitively impaired resident with Alzheimer's disease was left unsupervised during an aerosol treatment, resulting in the nebulizer tubing being detached from the face mask. An LPN later confirmed the resident's inability to self-administer the treatment, contrary to facility policy requiring supervision.
The facility was found to have expired supplies in two medication storage rooms. A urinary catheter and tuberculin syringes were expired in one room, while expired tuberculin safety syringes were found in another. A nurse stated it was the staff's responsibility to check for expired items. The facility's policy requires expired items to be stored separately until disposal or return.
A resident with hypothyroidism did not receive a routine lab test to monitor thyroid levels as ordered by a physician. The lab was unable to obtain the necessary blood sample, and the test was missed. The facility's Executive Director confirmed the oversight, and the nursing staff was responsible for obtaining the labs.
A resident with hemiplegia and major depressive disorder did not receive timely dental services for bottom dentures despite consenting to care and having a care plan in place. The facility's Social Services Director could not confirm any dental services provided to the resident, highlighting a failure in executing the facility's policy to assist with scheduling and arranging dental appointments.
A resident with recurrent UTIs was inappropriately treated with Macrobid for a UTI caused by Proteus mirabilis, an organism naturally resistant to this antibiotic. Despite culture results indicating resistance, the treatment was continued, contrary to the facility's Antimicrobial Stewardship Program policy.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the Indiana Department of Health (IDOH) in a timely manner for one resident. Resident B, who has diagnoses including anxiety and depression, reported an incident involving a Certified Nursing Assistant (CNA) who allegedly grabbed her arm, shook her, and verbally abused her. This incident was reported by Resident B to the night shift nurse and also communicated via email to the Business Office Manager (BOM) the following morning. Despite the BOM's acknowledgment and initiation of an investigation, the allegation was not reported to the IDOH until several days later. The delay in reporting was attributed to a miscommunication regarding responsibility for reporting in the absence of the Administrator, who was on vacation. The BOM assumed the Assistant Director of Nursing (ADON) was responsible for reporting the incident. The facility's policy mandates that any allegation of abuse must be reported immediately, but not more than two hours after the allegation, or within 24 hours if it does not involve serious bodily injury. The report to IDOH was only made on 10/11/24, several days after the incident was initially reported by Resident B.
Improper Garbage Disposal
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, affecting all 52 residents. During a kitchen tour with the Dietary Manager (DM), it was observed that the outside dumpster area had issues with trash containment. Specifically, one of the dumpsters had its left lid completely open, with a clear bag of trash and a blue glove on the ground nearby. Several bags of trash were also visible inside the open dumpster. The DM indicated she was unable to reach the dumpster door to close it. Subsequent observations on the following days confirmed that the same dumpster lid remained open. The facility's Garbage and Rubbish Disposal policy requires all containers to have tight-fitting lids and for outdoor trash receptacles to be covered, which was not adhered to in this instance.
Failure to Provide Bedside Fluids for Residents
Penalty
Summary
The facility failed to ensure that fluids were available at the bedside for seven residents, leading to a deficiency in accommodating the needs and preferences of these residents. Observations and interviews revealed that residents did not have access to fresh ice water, which was supposed to be provided at least three times a day according to the facility's policy. Residents 21, 31, 35, 41, 43, 19, and 30 were all observed without water at their bedsides during various times, and some residents reported that they rarely received fresh ice water. Resident 21, who was cognitively intact, reported that ice water was no longer passed at night, and they had to get water themselves. Similarly, Resident 35, also cognitively intact, indicated that fresh ice water was rarely provided. Resident 41, who was cognitively intact, mentioned that the only water available was for flushing out their feeding tube. Resident 43, another cognitively intact individual, noted that ice water was hardly brought into their room. These observations were consistent over multiple days, indicating a systemic issue in the facility's hydration practices. Residents 19 and 30, both cognitively impaired and dependent on staff for daily tasks, were also found without fluids in their rooms. Interviews with staff, including CNAs, revealed that the passing of water depended on their workload and was not consistently done. The Executive Director confirmed that all staff could pass fluids, but it was primarily the responsibility of direct care staff to ensure fresh fluids were provided every shift. The facility's policy on hydration was not being adhered to, resulting in the deficiency noted by the surveyors.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving resident-to-resident altercations. Resident 45, who was severely cognitively impaired and had a history of combative behavior and hallucinations, was involved in several altercations with other residents. These incidents included being smacked by a male resident and engaging in physical fights with other residents, such as Resident 31 and Resident 2. The facility's care plans for these residents indicated goals to prevent harm and reduce aggressive behaviors, but these measures were not effectively implemented. Resident 31, diagnosed with bipolar disorder, depression, psychotic disorder, and schizophrenia, was involved in an altercation with Resident 45, where both residents physically attacked each other. Another incident involved Resident 31 slapping Resident 33, who had a traumatic brain injury, in the face and back of the head. These incidents were witnessed by staff, and the facility's investigative files included interviews with staff members who were present during the altercations. Despite the presence of staff and administration, the facility failed to prevent these occurrences of physical abuse. Resident 2, diagnosed with dementia and schizophrenia, was also involved in an altercation with Resident 45, where he struck her in the eye. Similarly, Resident 13, with schizoaffective disorder and major depression, was hit by Resident 45. The facility's policy on abuse prevention and reporting was not effectively enforced, as evidenced by the repeated incidents of resident-to-resident abuse. The facility's failure to protect residents from physical abuse and to implement effective interventions for residents with aggressive behaviors led to these deficiencies.
Deficiencies in Linen and PPE Management
Penalty
Summary
The facility failed to properly manage soiled linen and personal protective equipment (PPE) disposal, leading to several deficiencies. Observations revealed that soiled linen was not bagged and was overflowing from bins in the hallways, preventing the lids from closing. Certified Nursing Assistants (CNAs) were observed transporting soiled linen without using bags, contrary to the facility's Linen Handling Principles policy. This policy mandates that soiled linens be bagged at the location of use and not transported openly through corridors. Interviews with CNAs indicated a lack of adherence to these guidelines, as they admitted to placing unbagged linen into hallway bins. Additionally, the facility did not ensure proper disposal of PPE used in rooms with residents under Enhanced Barrier Precautions (EBP). Observations showed uncovered trash receptacles in hallways outside rooms of residents in EBP, containing visible used PPE such as gowns and gloves. Interviews with the Assistant Director of Nursing (ADON) revealed that staff were doffing PPE in the hallway and discarding it in uncovered receptacles, which lacked lids. The ADON acknowledged the issue but was unaware of the location of the lids, indicating a lapse in maintaining proper infection control measures.
Failure to Maintain a Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for two residents, as observed during a survey. Resident 43, who has diagnoses including type 2 diabetes mellitus, alcoholic cirrhosis of the liver, and schizophrenia, was found to have a sticky bathroom floor, an uncovered bedpan, an open bag of adult diapers on the floor, and peeling paint on the walls behind the bed frames. The Executive Director (ED) acknowledged awareness of the paint issue, attributing it to the residents moving their beds and scuffing the walls, despite maintenance efforts to repaint. Resident 31, with diagnoses including chronic obstructive pulmonary disease, cerebral infarction, heart failure, and hypertension, was observed to have a bathroom floor littered with a Styrofoam cup, lid, straw, wash basin, and toilet paper. Additionally, the toilet bowl lid was found off and placed on the floor. The ED indicated that the resident had removed the lid, which was later replaced. The resident's care plan, revised earlier in the year, stated the provision of a homelike environment, and the admission packet confirmed the right to a safe, clean, and comfortable environment.
Failure to Provide Bed Hold Policy Documentation
Penalty
Summary
The facility failed to maintain documentation that Resident 5's representative was provided with a bed hold policy during a hospitalization. Resident 5, who had a diagnosis of stroke and was cognitively intact according to a recent MDS assessment, went on a therapeutic leave from July 22 to July 26, 2024. During an interview, Resident 5 stated he was unaware of the bed hold policy and did not receive any related paperwork before his hospital transfer in July 2024. The Executive Director confirmed that the staff could not locate the bed hold policy for Resident 5's hospitalization, although it was expected that nursing staff would provide this policy at the time of transfer. A blank copy of the Bed Hold Policy Notice was later provided by the Executive Director.
Inaccurate MDS Encoding for Two Residents
Penalty
Summary
The facility failed to accurately encode Minimum Data Set (MDS) information for two residents, leading to deficiencies in their assessments. Resident 5, diagnosed with bipolar disorder, was inaccurately recorded as not having a PASARR Level II assessment, despite having a serious mental illness documented in a PASARR Level II dated 6/21/19. The Social Services Director confirmed the presence of this serious mental illness and the outdated PASARR Level II assessment. Resident 19, with a diagnosis of chronic obstructive pulmonary disease, was inaccurately recorded in a Quarterly MDS assessment as not having a prognosis of six months or less, despite receiving hospice services. A hospice care plan and a certification of terminal illness indicated a terminal diagnosis with a life expectancy of six months or less. The MDS Nurse acknowledged that these assessments were coded incorrectly due to oversight. The facility's policy requires all assessments to be completed timely and accurately, as per the Resident Assessment Instrument Manual.
Failure to Complete PASARR Level II for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level II was completed for Resident 11, who was diagnosed with schizophrenia, prior to their admission. The clinical record review revealed that the Admission Minimum Data Set (MDS) assessment dated February 1, 2024, indicated the absence of a PASARR Level II for Resident 11. According to the Indiana State Department of Family and Social Services Administration, all applicants to Medicaid-certified nursing facilities must undergo a Level I screen to initiate the PASARR process, and if necessary, a Level II evaluation is conducted to identify specialized needs for individuals with mental illness or intellectual/developmental disabilities. A PASARR Level I for Resident 11, dated January 24, 2019, indicated the need for an on-site Level II review, which was not completed. During an interview, the Social Service Director (SSD) acknowledged the lack of documentation for a Level II review after January 24, 2019, attributing the oversight to an influx of residents at the time of Resident 11's admission. The facility's policy on PASARR, provided by the Director of Nursing, stated that the facility would participate in or complete the Level I screen for all potential admissions and refer individuals requiring a Level II screening to the State PASARR representative.
Failure to Conduct Scheduled Care Plan Meetings
Penalty
Summary
The facility failed to hold regularly scheduled care plan meetings for a resident, identified as Resident 45, who was admitted with diagnoses including dementia and major depressive disorder. Upon review of the clinical records, it was found that although an Admission MDS assessment was completed on 11/14/23 and a Quarterly MDS assessment on 5/1/24, there were no corresponding care plan meetings documented. A care plan meeting was scheduled for 5/23/24, but there was no evidence that it took place. Additionally, there was no documentation of a care plan meeting following the resident's admission in November 2023. Family Member 2, who is associated with Resident 45, reported not having any scheduled care plan meetings with the facility to discuss missed medical appointments. The Social Services Director, in the presence of the ADON, confirmed the absence of documentation for the care plan meetings and was unable to verify if the scheduled meeting in May 2024 occurred. The facility's Comprehensive Care Plan policy requires that care plan meetings be held quarterly and that residents and their representatives be invited to participate, but this was not adhered to in the case of Resident 45.
Failure to Provide Scheduled and Outdoor Activities
Penalty
Summary
The facility failed to adhere to its scheduled activities calendar and provide outdoor activities for residents, as observed in the cases of three residents. Resident 35, who has multiple diagnoses including fibromyalgia and type 2 diabetes, reported that scheduled card games did not occur due to the unavailability of cards. Additionally, Resident 35 expressed a desire to participate in outings, but was informed by the facility that transportation limitations prevented such activities. Resident 41, diagnosed with conditions such as acute respiratory failure and major depressive disorder, also expressed dissatisfaction with the lack of outings. Despite being cognitively intact and having a care plan that noted his enjoyment of outdoor activities, Resident 41 reported that the facility had not organized any community outings since February 2024. The Activities Director confirmed the transportation constraints, noting the facility's small van capacity as a limiting factor. Resident 34, with diagnoses including hemiplegia and hypertension, experienced a lack of scheduled activities. On multiple occasions, activities listed on the calendar, such as the Daily Chronicle and Church services, did not occur. Resident 34 was unaware of certain activities and expressed a desire for more off-site activities, which were not reflected in his care plan. Observations confirmed that scheduled activities were not taking place, and the facility's activity policy was not being followed, as evidenced by the lack of organized activities and the absence of outings on the calendar.
Failure to Document Dressing Changes and Conduct Skin Assessments
Penalty
Summary
The facility failed to properly manage the care of two residents with skin impairments. For Resident 1, who has schizophrenia and is cognitively impaired, the facility did not date, time, or initial the dressing applied to a non-pressure wound on the forehead. Observations on consecutive days revealed that the dressing lacked these details, and the staff member responsible for the dressing change was not identified. An LPN confirmed the omission and was unaware of when the dressing was last changed. For Resident 34, who has hemiplegia, hemiparesis, and a history of cerebral vascular accident, the facility did not complete the required skin assessments as outlined in the care plan. Despite being on antiplatelet therapy, which can cause skin changes, only one skin assessment was documented in August, which did not include the resident's arms where dark spots were present. The DON acknowledged the lack of documentation for the required daily skin inspections and weekly assessments, as per the facility's policy.
Failure to Provide Timely Optometry Services
Penalty
Summary
The facility failed to provide timely optometry services to a resident who had consented to receive such services. Resident 34, who had diagnoses including hemiplegia, hemiparesis, major depressive disorder, and hypertension, was admitted to the facility and had a care plan indicating consent for optometry services. Despite a physician's order from October 2022 allowing optometry visits as needed and an assessment in August 2024 indicating the need for assistance with corrective lenses, there were no records of optometry consultations in the resident's clinical record. An interview with the Social Services Director (SSD) revealed that the facility used a specific provider for optometry services, who was responsible for gathering consent forms and scheduling appointments. The SSD, who had been working at the facility since November 2023, indicated that the optometry provider was in the facility in August 2024, but Resident 34 was not seen during that visit. The SSD confirmed that Resident 34 had not received optometry services at the facility since the SSD began working there. The facility's policy stated that it would assist residents in arranging on-site health services as needed, but this was not fulfilled for Resident 34.
Failure to Complete Quarterly Smoking Assessments
Penalty
Summary
The facility failed to complete quarterly smoking assessments for a resident who was reviewed for smoking safety. The resident, who was cognitively intact and had a diagnosis of chronic obstructive pulmonary disease, was identified as a cigarette smoker. The resident's smoking care plan required smoking assessments to be conducted upon admission, quarterly, and as needed. However, during an interview, the Executive Director acknowledged that the staff could not locate the quarterly smoking assessment for the resident for the past year. The responsibility for completing these assessments was shared between activities and social services. The facility's policy on smoking safety also stipulated that smoking assessments should be completed at admission, quarterly, and as needed.
Inadequate Supervision During Aerosol Treatment
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired resident, Resident 30, during the administration of an aerosol generating procedure. Resident 30, who has Alzheimer's disease and is dependent on staff for all activities of daily living, was observed with a nebulizer running but the tubing was detached from the face mask, which was placed under the resident's chin. This observation occurred while Resident 30 was alone in their room, indicating a lack of supervision during the administration of the aerosolized medication. Licensed Practical Nurse (LPN) 13, upon entering the room, acknowledged that Resident 30 frequently pulls off the treatment and confirmed that the resident should be supervised during the administration of aerosolized medication, as they are not capable of self-administering the treatment. The facility's policy on nebulizer medication administration requires staff to remain with the resident during treatment unless the resident has been assessed and authorized to self-administer, which was not the case for Resident 30.
Expired Supplies Found in Medication Storage Rooms
Penalty
Summary
The facility failed to ensure that medication storage rooms were free of expired supplies, as observed in two medication rooms. During an inspection, a urinary catheter with an expiration date of 2022 and a box of tuberculin syringes with an expiration date of 2023 were found in one medication storage room. In another room, a box of tuberculin safety syringes and six individual safety syringes were found to be expired. A registered nurse indicated that it was the responsibility of the nursing staff to check the medication storage rooms to ensure that supplies were not expired. The facility's policy on medication storage, revised on an unspecified date, stated that expired medications and biologicals should be stored separately until they are destroyed or returned to the supplier.
Missed Routine Lab Test for Resident with Hypothyroidism
Penalty
Summary
The facility failed to ensure that a routine laboratory test was conducted for a resident, identified as Resident 19, who was diagnosed with hypothyroidism. The resident's clinical record was reviewed, revealing a physician's order dated May 23, 2024, which required routine laboratory tests every six months to monitor thyroid levels. However, a nursing progress note from the same date indicated that the lab was unable to obtain the necessary blood sample for the tests and planned to try again on the next lab day. Despite this, the Executive Director confirmed during an interview that the facility could not find any record of the thyroid level lab being obtained in May 2024, resulting in a missed test. The nursing staff was responsible for ensuring that labs were obtained as per the physician's order.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services to a resident, identified as Resident 34, who required bottom dentures. Resident 34, who was cognitively intact and had diagnoses including hemiplegia, hemiparesis, major depressive disorder, and hypertension, was admitted to the facility with a care plan indicating the need for routine dental referrals. Despite consenting to dental services and having a physician's order for dental consultations as needed, there were no records of dental consultations in his clinical record. An observation and interview with Resident 34 revealed that he had not seen a dentist since his admission and was missing bottom dentures. The Social Services Director (SSD) confirmed that the facility used a specific provider for dental services, who was responsible for gathering consent forms and scheduling appointments. However, the SSD, who had been working at the facility since November 2023, could not confirm any dental services provided to Resident 34 during their tenure. The facility's policy stated that they would assist residents in scheduling dental appointments and arranging transportation if necessary, but this was not executed for Resident 34, leading to the deficiency.
Inappropriate Antibiotic Use for UTI Treatment
Penalty
Summary
The facility failed to ensure the appropriate use of antibiotics for the treatment of a urinary tract infection (UTI) in a resident with a history of dementia, psychotic disorder, and recurrent UTIs. On July 9, 2024, a urine specimen was collected for urinalysis with culture and sensitivity testing. The following day, a physician noted a possible UTI and planned to start the resident on Macrobid if the culture results were not available. By July 11, 2024, a care plan was initiated indicating the resident had a UTI, and Macrobid was prescribed. On July 12, 2024, the culture results identified the organism as Proteus mirabilis, which is naturally resistant to Macrobid. Despite this, the Nurse Practitioner was notified and decided to continue the Macrobid treatment. The facility's Antimicrobial Stewardship Program policy, which promotes appropriate antibiotic use, was not adhered to in this instance, as the prescribed antibiotic was not suitable for the identified organism.
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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