Aperion Care Kokomo
Inspection history, citations, penalties and survey trends for this long-term care facility in Kokomo, Indiana.
- Location
- 3518 S Lafountain St, Kokomo, Indiana 46902
- CMS Provider Number
- 155064
- Inspections on file
- 41
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Aperion Care Kokomo during CMS and state inspections, most recent first.
A resident with multiple risk factors for skin breakdown, including Parkinson’s disease, incontinence, and impaired mobility, developed a facility-acquired Stage III pressure ulcer on the coccyx after a lapse in documented preventive hydrocolloid dressings. The resident had complained of soreness before staff discovered the open area during care, and although staff later reported the wound to the wound nurse, there was no clinical documentation on the day it was first found describing who discovered it, when it was found, or its measurements and characteristics. A subsequent wound summary documented a Stage III pressure ulcer caused by pressure, while facility policy required immediate wound assessment, detailed documentation, and measurement when skin breakdown is identified, leading to the cited deficiency.
A resident with paraplegia was admitted to a facility with a loaner wheelchair, which was lost after admission. Despite being transported in the wheelchair, it was not documented, and staff were unaware of its location. The facility failed to uphold the resident's right to retain personal possessions, resulting in a deficiency citation.
A facility failed to accurately assess and document a resident's pressure ulcer upon admission, leading to a deterioration from an almost healed state to a Stage 4 ulcer. The initial and subsequent assessments lacked comprehensive details such as size, stage, and drainage, contrary to the facility's policy. The resident had a history of paraplegia and muscle atrophy, and the responsible ADON had left the facility around the time of admission.
A resident with a history of neurogenic bladder and paraplegia experienced trauma due to improper catheter placement by facility staff. Two nurses inserted oversized catheters incorrectly, causing bleeding and hematuria. Hospital evaluation confirmed the catheter was malpositioned, with the balloon inflated within the penile urethra. Facility documentation failed to note urine return, a critical step in proper catheter placement.
A resident was unable to access personal funds due to errors in fund management and lack of a dedicated business office manager. The resident's check was misallocated, and complications arose after discharge and readmission, delaying access to funds.
A resident with a complex medical history was not provided with the care plan interventions of 1:1 supervision and a mattress for safety, as the care plan was not updated after their return from a psychiatric facility. The DON confirmed the care plan was outdated, contrary to the facility's policy requiring regular reviews and revisions.
The facility failed to administer oxygen at the correct flow rate for two residents. One resident with COPD and other conditions was observed receiving 2 LPM instead of the ordered 3 LPM. Another resident with acute respiratory failure and other diagnoses was observed receiving oxygen at 4 LPM and between 3 and 3.5 LPM, contrary to the physician's order of 3 LPM. Staff confirmed the discrepancies, and the facility's policy requires physician verification for any changes in oxygen orders.
The facility failed to maintain RN coverage for at least 8 consecutive hours daily on several occasions during the third quarter of 2024. The DON confirmed that an RN was on call but not present in the building on specific days, and the facility lacked a staffing policy despite following state guidelines.
A resident with an overactive bladder missed several doses of Oxybutynin due to medication unavailability, resulting in increased incontinence. The facility failed to follow its policy of documenting unavailable medications and contacting the pharmacy, leading to a seven-day lapse in medication administration.
A facility failed to properly label and store medications, as observed in a medication cart where two bottles of eye drops for a resident were found opened without open dates, and six loose, unidentified pills were present. A QMA confirmed the eye drops should have been dated and loose medications removed. The facility's policy requires certain medications to have a shorter expiration date once opened.
The facility failed to serve food at proper temperatures and did not adhere to puree recipes, affecting nutritional adequacy. A resident reported receiving cold meals and unrequested menu substitutions. Observations confirmed improper food temperatures and incorrect puree preparation by two cooks, as noted by the Dietary Manager.
The facility failed to ensure residents were treated with respect and dignity by an LPN, who dismissed a resident's request for pain medication, used profanity towards another resident, and yelled at two residents for being in restricted areas. These actions violated the facility's policies on resident rights and employee conduct.
The facility failed to protect residents from theft, as evidenced by a staff member not returning change after purchasing food and drinks for two residents. One resident gave the CNA fifty dollars for food, but the CNA did not return the change. Another resident gave the CNA four dollars for a candy bar and drink, but the CNA did not return the sixty-five cents in change. The CNA was terminated for violating company policy.
Failure to Prevent and Timely Assess a Facility-Acquired Stage III Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to prevent the development of a pressure ulcer and to complete a timely wound assessment for a resident who was admitted without pressure ulcers. The resident had multiple diagnoses including Parkinson’s disease, history of falls, incontinence, gait and mobility abnormalities, muscle weakness, and diarrhea. The ETAR for November showed that a hydrocolloid dressing was used on the coccyx as a preventive measure from the 1st to the 15th, but there was no physician order or documentation of any preventive dressing from the 15th through the 26th. On the 27th, a hydrocolloid dressing was documented as being applied to the tailbone after cleansing a wound, indicating that an open area had already developed. The resident reported that staff discovered the sore on the coccyx during bathing, after he had complained of soreness in that area. A nursing progress note on the 28th documented that the resident refused to get out of bed and resisted turning and repositioning, despite being educated on the importance of offloading pressure. A facility pressure injury document dated the 28th at 4:00 p.m. indicated staff had reported a new area on the coccyx to the wound nurse, and that the resident was unaware of the area. This document also stated that the wound was found on the night of the 26th at 10:30 p.m., but there was no clinical record entry on the 27th describing who found the wound, the time it was found, its measurements, or wound characteristics. A wound summary dated the 28th at 4:38 p.m. documented that the resident had a facility-acquired Stage III pressure ulcer on the coccyx, with specific measurements and tissue description, and identified pressure as the cause. Subsequent hospital and wound physician documentation described the same coccyx/sacral wound as an unstageable pressure injury at one point and later as a Stage III ulcer with changing measurements and tissue composition. The facility’s skin assessment policy required that when pressure or other skin conditions are identified, a wound assessment be initiated and documented in the chart, with the initial observation described in nursing progress notes and measurements obtained using appropriate tools. The lack of timely documentation and assessment on the date the wound was first identified, combined with the gap in documented preventive measures, led to the cited deficiency for failure to ensure a resident without a pressure ulcer did not develop one and that a wound assessment was completed when the wound was discovered.
Loss of Resident's Specialized Wheelchair
Penalty
Summary
The facility failed to ensure the respect and retention of a resident's personal property, specifically a specialized wheelchair, after the resident's discharge. Resident B, who had medical conditions including flaccid neuropathic bladder, complete paraplegia, and muscle wasting and atrophy, was admitted to the facility with a loaner Quickie QRI blue wheelchair from a specialized company. Upon admission, the resident was transported in the wheelchair, but it was not documented in the admission records. The Executive Director and other staff members were unaware of the wheelchair's whereabouts after the resident was placed in bed, and the wheelchair was never seen again. Interviews with various staff members and external parties confirmed that the resident was transported to the facility in the loaner wheelchair, which was intended for use until a custom wheelchair was made. Despite efforts to locate the wheelchair, including a request for a description from the resident's mother, the facility was unable to find it. The facility's policy on resident rights, which includes the right to retain and use personal possessions, was not upheld in this instance, leading to a deficiency citation related to the complaint.
Failure to Accurately Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to ensure an accurate admission assessment of a resident's pressure ulcer by a licensed nurse qualified to assess pressure wounds, as per their policy and procedure. Upon admission, the resident had a pressure ulcer that was almost healed, but it worsened to a Stage 4 ulcer by the time the resident was hospitalized. The initial assessment documented a sacrum pressure area with a yellowish and white wound bed, but it lacked details such as the stage of the ulcer and drainage observations. Subsequent documentation also failed to include comprehensive details like size, stage, odor, drainage, and description of the pressure wounds. The resident's clinical record indicated a history of flaccid neuropathic bladder, complete paraplegia, and muscle wasting and atrophy. A previous wound care note from a rehabilitation hospital documented a sacral Deep Tissue Injury that evolved to an unstageable pressure wound. The facility's policy required weekly assessments and documentation of pressure ulcers, but these were not consistently or accurately completed. The Director of Nursing noted that the previous Assistant Director of Nursing, who was responsible for wound assessments, had left the facility around the time of the resident's admission.
Improper Catheter Placement Leads to Resident Trauma
Penalty
Summary
The facility failed to ensure proper catheter care for a resident with an indwelling catheter, leading to trauma and hospitalization. Prior to the resident's hospital admission, two nurses improperly placed indwelling catheters, causing trauma to the resident's urinary tract. The first nurse inserted a catheter that was too large, resulting in blood in the catheter, necessitating its removal. Subsequently, a second nurse also inserted an oversized catheter incorrectly, which was later found to be malpositioned with the balloon inflated within the penile urethra, causing penile bleeding and hematuria. The resident, who had a medical history of flaccid neuropathic bladder, complete paraplegia, and muscle wasting, experienced significant complications due to the improper catheter placement. Nursing progress notes indicated that the catheter was initially inserted without difficulty, but later entries revealed dark red fluid in the catheter and blood clots draining into the catheter bag. A hospital emergency department report confirmed the catheter's malpositioning, and a CT scan further verified the incorrect placement. The facility's policy on catheterization was not followed, as there was no documentation of urine return or the color of the urine, which are critical steps in ensuring proper catheter placement.
Failure to Provide Resident Access to Personal Funds
Penalty
Summary
The facility failed to ensure that a resident was able to access personal funds when requested, as required by their policy. Resident 36 reported that she had asked several times to withdraw money from her account but was unable to do so. An error occurred when the Corporate Business Office Manager deposited the resident's check into the Accounts Receivable (AR) side instead of the Resident Fund Management Service (RFMS) account. This mistake was compounded by the fact that the facility did not have a dedicated business office manager, and the Corporate Business Office Manager was responsible for multiple facilities. Further complications arose when Resident 36 was discharged and then readmitted to the facility, leading to issues with her funds. The resident's social security check was initially rejected by the RFMS, requiring the facility to reapply, which delayed access to her funds. Additionally, a check for $333.00 was deposited entirely into the facility's patient liability billing account, with no portion allocated to the resident's personal account. The facility's policy stated that residents should have access to their funds within three banking days, but this was not adhered to in this case.
Failure to Update Care Plan for Resident Safety
Penalty
Summary
The facility failed to ensure that a care plan was reviewed and revised appropriately for a resident who was observed with a mattress on the floor beside their bed. The resident, who had a complex medical history including seizures, schizoaffective disorder, depression, and dementia, was not observed to be on a 1:1 staff supervision as indicated in their care plan. The care plan, dated several months prior, included interventions such as 1:1 supervision and a mattress against the wall for safety, but these interventions were not being followed. The Director of Nursing confirmed that the care plan had not been updated to reflect changes in the resident's needs following their stay at an inpatient psychiatric facility. The facility's policy required that care plans be reviewed and revised by the interdisciplinary team after each assessment, but this was not done in this case, leading to the deficiency.
Failure to Administer Oxygen at Correct Flow Rate
Penalty
Summary
The facility failed to administer oxygen at the correct flow rate as ordered by the physician for two residents. Resident 32, who has a history of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, asthma, atrial fibrillation, and anxiety disorder, was observed receiving oxygen at a flow rate of 2 liters per minute (LPM) via a nasal cannula on multiple occasions. However, the physician's order and the Medication Administration Record (MAR) indicated that the resident should have been receiving 3 LPM continuously. The Assistant Director of Nursing confirmed that the oxygen was being administered at 2 LPM instead of the ordered 3 LPM. Similarly, Resident 43, diagnosed with acute respiratory failure with hypoxia, COPD, anxiety, chronic kidney disease, and arteriosclerotic heart disease, was observed receiving oxygen at a flow rate of 4 LPM and between 3 and 3.5 LPM, contrary to the physician's order of 3 LPM. The MAR also indicated that the resident should have been receiving 3 LPM. An LPN confirmed that the oxygen should have been administered at 3 LPM as per the physician's order. The facility's policy on oxygen safety emphasized that oxygen is a prescribed drug and any changes in the order must be verified by a physician before implementation.
RN Coverage Deficiency
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present in the facility for at least 8 consecutive hours a day, 7 days a week, during the third quarter of 2024. Specifically, there was no RN coverage on the dates of 8/10, 8/11, 8/31, 9/1, and 9/14. A review of the Payroll-Based Journal (PBJ) staffing report confirmed the absence of licensed nursing coverage for 24 hours a day on these dates. During interviews, the Director of Nursing (DON) acknowledged that RN 2 was on call but not physically present in the building on the specified days. Additionally, the Scheduler noted that apart from management staff, the facility had only one RN who worked every other weekend. The facility did not have a specific policy for staffing, although it followed state regulations and guidelines.
Medication Unavailability Leads to Resident's Missed Doses
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for a resident, leading to a deficiency in pharmaceutical services. Resident 4, who had a diagnosis of overactive bladder among other conditions, missed her scheduled doses of Oxybutynin for several days. The resident reported missing her medication for two days initially, which resulted in several incontinent episodes. Despite having a physician's order for daily administration of Oxybutynin, the medication was not available, and the staff informed her that the pharmacy had not delivered it. Upon further investigation, it was found that the resident went without her medication for seven days, as confirmed by the Director of Nursing. The medication was not located in the medication cart or the Emergency Drug Kit, and it was only found later in the bottom of the medication cart. The facility's policy required staff to document unavailable medications and contact the pharmacy, which was not done in this case. The resident's incontinent episodes decreased once she received her medication again.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, specifically eye drops and loose pills, in one of the medication carts reviewed. During an observation, two bottles of eye drops for a resident were found opened in the top drawer of the medication cart without any open dates on the bottles or their plastic bags. Additionally, the second drawer of the medication cart contained six loose, unidentified medications, including one large green pill, two round white pills, two oval white pills, and one small round yellow pill. A physician's order indicated that the resident was to receive one drop of prednisolone acetate ophthalmic suspension in both eyes. During an interview, a QMA confirmed that the eye drops should have been dated upon opening and that the loose medications should have been removed and destroyed. The facility's current policy on medication storage, which was undated, stated that certain medications require an expiration date shorter than the manufacturer's expiration date once opened, and that the nurse should place a date opened sticker on the medication.
Deficiencies in Food Temperature and Puree Recipe Adherence
Penalty
Summary
The facility failed to ensure that food was served at the proper temperature, that menus were followed, and that residents were offered substitutions of nutritional value of their choice. Resident 32 reported that the food often tasted terrible and was served cold, with specific instances of receiving cold fish and room temperature coleslaw. Additionally, Resident 32 noted that menu substitutions occurred routinely without being consulted for preferences. An observation confirmed that the fish was served at an inadequate temperature of 118.9 degrees, below the required 145 degrees. Resident 32's medical history includes chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and other conditions, with a BIMS score indicating cognitive intactness. The facility also failed to follow puree recipes, impacting the nutritional adequacy of meals. During observations, it was noted that the cooks did not adhere to standardized recipes for pureed foods. One cook used incorrect measurements for milk, resulting in a runny garlic bread puree, while another cook added unmeasured amounts of milk to a cake puree, leading to improper consistency. The Dietary Manager confirmed that the cooks did not follow the recipes as required by the facility's policy on pureed food preparation, which mandates the use of standardized recipes to ensure quality and nutritional value.
Failure to Treat Residents with Respect and Dignity
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity by a staff member, specifically LPN 2, for four residents. Resident F requested a pain pill, and LPN 2 responded dismissively, stating she did not have time for that. Resident D was disrespected by LPN 2 when she asked to use a different shower room, and LPN 2 used profanity and told her to stay on her own hallway. Resident E did not receive her dinner tray and went to the kitchen, where LPN 2 yelled at her for being in a restricted area due to COVID-19 concerns. Resident B experienced multiple instances of disrespect from LPN 2. On one occasion, LPN 2 refused to assist him into his wheelchair and responded aggressively when he threatened to call the police. On another occasion, LPN 2 used profanity and yelled at Resident B for using his call light. These incidents were part of a pattern of behavior from LPN 2, who had multiple complaints against her for verbal aggression and unprofessional conduct towards residents. The facility's policies on resident rights and employee conduct emphasize the importance of treating residents with dignity and respect. However, LPN 2's actions violated these policies, leading to multiple complaints and ultimately her termination. The incidents highlight a failure to uphold the standards of care and respect required in the facility, impacting the residents' right to a dignified existence and self-determination.
Failure to Protect Residents from Theft
Penalty
Summary
The facility failed to ensure a resident was free from theft, as evidenced by a staff member not returning change after purchasing food for a resident. Resident C gave CNA 3 fifty dollars to purchase Taco Bell, but the CNA did not return the change. The investigation revealed that CNA 3 was given fifteen dollars for the food and ten dollars for gas, but kept the remaining money. Resident C reported that this was not the first time CNA 3 had asked to keep money for gas. The facility reimbursed Resident C for the ten dollars taken by CNA 3, who was subsequently terminated for violating company policy. Another incident involved Resident K, who gave CNA 3 four dollars to purchase a candy bar and a drink from the vending machine. The CNA did not return the sixty-five cents in change. The facility's investigation partially substantiated the concern, and CNA 3 admitted to placing the change in the resident's room. The facility's policy prohibits staff from taking money from residents, and CNA 3 was terminated for this violation.
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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