Aspen Place Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensburg, Indiana.
- Location
- 2320 N Montgomery Road, Greensburg, Indiana 47240
- CMS Provider Number
- 155797
- Inspections on file
- 30
- Latest survey
- June 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Aspen Place Health Campus during CMS and state inspections, most recent first.
The facility did not document or track antibiotic use for two months, contrary to its infection control policy. Additionally, staff failed to follow Enhanced Barrier Precautions by not wearing gowns during high-contact care for two residents with chronic wounds, despite physician orders and posted signage requiring this protective equipment.
Three certified nurse aides did not complete the required hours of dementia training before working with residents diagnosed with dementia. Training was distributed via email, and staff were responsible for completion, but records showed insufficient training hours for these aides. The facility did not have a specific policy on dementia training and relied on regulatory requirements.
A resident with multiple medical conditions reported that a CNA tossed a package of wet wipes at her, which she perceived as an act of anger. The incident was communicated to several staff members, but was not reported to the DON or Administrator in a timely manner. The DON later acknowledged that staff should have reported the allegation immediately, and the facility lacked a specific reporting policy.
A resident with severe cognitive impairment and multiple medical conditions did not have daily blood pressure checks documented as ordered by a physician over a specified period. Nursing staff confirmed that such monitoring should be recorded, but several days were missing documentation, and there was no facility policy for following physician orders, relying instead on standard practice.
Two residents with UTIs experienced delays in receiving antibiotic treatment due to late lab processing and medication unavailability. One resident with severe cognitive impairment had a delay between urine collection, lab reporting, and the start of antibiotics. Another resident with a urinary catheter did not receive prescribed antibiotics until several days after lab results were available. Staff interviews confirmed delays in lab result retrieval and treatment initiation, and the facility did not have a policy addressing timely lab processing.
The facility did not consistently monitor or document daily weights and PRN medication administration for a resident with heart disease and diabetes, nor did it consistently record meal intake for another resident with severe cognitive impairment and malnutrition, despite facility policy and physician orders requiring these actions.
A resident with severe cognitive impairment and multiple medical conditions missed several doses of prescribed tramadol because the medication was unavailable and a new prescription was not obtained in a timely manner. Documentation showed repeated missed doses and delays in communication with the provider, contrary to facility policy requiring advance reordering and prompt prescription renewal.
A QMA crushed and administered an extended-release Potassium Chloride tablet to a resident with severe cognitive impairment, despite the medication being on the facility's 'do not crush' list. The QMA was unaware of this restriction at the time, and the error was identified during a review of medication administration practices.
A medication cart was found to contain an insulin pen and a bottle of liquid fish oil for a resident, both of which were not labeled with the date they were opened. An RN confirmed that these medications should have been labeled according to facility policy and manufacturer instructions.
The facility failed to label and store medications properly, as observed with an insulin pen and TB serum in the 300 Hall. An LPN found an insulin pen without an opened-on date, and an RN found an undated TB serum vial. Both medications were used beyond their recommended periods, violating the facility's policy.
The facility failed to store food appropriately, with several items found in the walk-in refrigerator having expired use-by dates. The Dietary Manager indicated that it was the responsibility of the cooks, Assistant Dietary Manager, and herself to ensure outdated foods were discarded, with daily checks of the refrigerator. The weekend cook was responsible for checking the refrigerators on weekends.
A resident was observed with medications left at their bedside without a completed self-administration assessment, contrary to facility policy. The resident, who was cognitively intact, identified some medications but delayed taking a water pill. Staff interviews confirmed the lack of an assessment, which is required for self-administration of medications.
The facility failed to provide adequate bathing services for two residents, who were reviewed for Activities of Daily Living. A resident with atrial fibrillation, hypertension, and respiratory failure received only 6 out of 10 scheduled showers or complete bed baths. Another resident with a fracture, anemia, hypertension, and diabetes was non-compliant and refused showers, receiving or being offered a bath 11 out of 15 times. The facility's policy required bathing at least twice a week and proper documentation, which was not consistently followed.
A facility failed to follow infection control guidelines for a resident with an indwelling urinary catheter, leading to potential contamination. The resident, with a history of recurrent UTIs and requiring extensive assistance, was observed with catheter tubing and drainage bag touching the floor. Staff interviews confirmed the need for assistance and the facility's policy to keep catheter equipment off the floor, which was not adhered to.
A facility failed to follow hospital discharge orders and verify admission weights for a resident with conditions including atrial fibrillation and respiratory failure. The resident's discharge instructions required daily weighing, a low sodium diet, and fluid intake monitoring, which were not documented or followed by the facility. Staff interviews revealed lapses in transcribing and verifying physician orders, and the Director of Nursing acknowledged the oversight in addressing weight discrepancies.
Failure to Track Infections and Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control guidelines in two main areas: infection tracking and trending, and the implementation of Enhanced Barrier Precautions (EBP). Record review revealed that the facility did not document or track antibiotic use for the months of February and March 2025. The Infection Preventionist confirmed that no tracking occurred during this period, as she only began her role in April. This lack of documentation was inconsistent with the facility's own infection prevention and control policy, which requires ongoing surveillance and reporting of infections and antibiotic usage. Additionally, staff did not consistently follow EBP protocols for residents with chronic wounds. One resident with severe cognitive impairment and an unhealed pressure ulcer had a physician's order and signage indicating the need for staff to wear gowns and gloves during high-contact care. However, a registered nurse provided wound care without donning a gown. Similarly, another resident with pressure and venous ulcers had an order for EBP, but two registered nurses performed wound care without wearing gowns. Both instances were observed and acknowledged by the staff involved, and were not in accordance with the facility's EBP policy.
Failure to Provide Required Dementia Training to Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required six hours of dementia training within six months of hire and three hours annually, as evidenced by a review of 10 employee records. Specifically, three certified nurse aides working on the skilled unit did not have the mandated number of dementia training hours prior to working with residents diagnosed with dementia. One aide had only 1.5 hours, another had 1 hour, and a third had 1.5 hours of dementia training. The Employee Experience Manager confirmed that all documented dementia training was provided through email and it was the staff's responsibility to complete it, with department managers receiving reports on outstanding training. There was no facility policy on dementia training, and the facility relied on state and federal regulations.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for one resident. The incident involved a cognitively intact resident with multiple diagnoses, including anemia, heart failure, hypertension, diabetes, malnutrition, depression, and bipolar disorder. The resident reported that a CNA tossed a package of wet wipes at her in the bathroom, which she perceived as an act of anger. The resident communicated her dissatisfaction to other staff members, but did not believe the issue was addressed. The CNA involved stated that she did not throw the wipes, but acknowledged the wipes hit the resident's wheelchair. The incident was discussed among staff, including a nurse and a Qualified Medication Aide, but the resident was unwilling to discuss the matter further in the presence of the CNA. The Director of Nursing (DON) became aware of the accusation several days after the incident and initiated an investigation. Statements were collected from the resident, CNA, LPN, and QMA, all confirming that the resident had reported the incident. However, the DON acknowledged that the staff should have reported the allegation of abuse immediately to her or the Administrator, as per facility expectations. The Administrator also indicated there was no specific policy for reporting, and that state guidelines would be followed. The delay in reporting the allegation constituted a failure to meet timely reporting requirements for suspected abuse.
Failure to Follow Physician Order for Blood Pressure Monitoring
Penalty
Summary
The facility failed to follow a physician's order for daily blood pressure monitoring for one resident who was severely cognitively impaired and had multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, non-Alzheimer dementia, malnutrition, anxiety, depression, and psychotic disorder. The physician's order required daily blood pressure checks from 01/30/25 through 02/24/25, but the resident's clinical record lacked documentation of blood pressure readings on several specified dates within this period. Interviews with nursing staff confirmed that such monitoring should be documented in the Electronic Medication Administration Record, and the Corporate Clinical Support Nurse stated there was no specific policy for following physician orders, relying instead on standards of practice.
Delayed Antibiotic Treatment for UTIs Due to Lab and Medication Delays
Penalty
Summary
The facility failed to ensure timely antibiotic treatment for residents diagnosed with urinary tract infections (UTIs) for two of fifteen residents reviewed. For one resident with severe cognitive impairment and multiple comorbidities, urine was collected for a urinalysis and culture, but there was a delay in both the laboratory processing and the initiation of antibiotic therapy. The urine sample was collected and received by the lab two days later, with culture results reported four days after collection. Despite the positive UTI result, antibiotic treatment was not started until three days after the results were available. For another resident with neurogenic bladder and a urinary catheter, urine was collected and refrigerated for lab pickup, and the catheter was replaced due to leaking. The urine culture results were reported within three days, but the antibiotic prescribed was not administered until four days after the results were available due to medication unavailability. Interviews with nursing staff and the infection preventionist confirmed that there were delays in obtaining lab results and starting antibiotics, and the facility lacked a policy on the timeliness of lab processing and treatment initiation.
Failure to Monitor and Document Nutrition and Fluid Status for Two Residents
Penalty
Summary
The facility failed to adequately monitor and document the nutritional and fluid status of two residents with significant medical conditions. For one resident with diagnoses including heart disease, hypertension, and diabetes, there were multiple dates where daily weights were not recorded as ordered by the physician. Additionally, when the resident experienced weight gains of two pounds or more in a day, the prescribed PRN dose of Lasix was not administered as required. Staff interviews confirmed that weights were to be obtained daily and reported to the nurse, who would then determine if the PRN medication should be given, but this process was not consistently followed. The facility also lacked a policy for following physician orders, relying instead on standard practice. For another resident with severe cognitive impairment and a diagnosis of malnutrition, the clinical record was missing documentation of meal intake for numerous meals across several dates. Facility policy required that meal intake be recorded in the electronic health record, but this was not consistently done. Staff interviews confirmed that meal documentation was expected, but the records showed significant gaps, particularly for a resident at risk due to malnutrition.
Failure to Provide Timely Medication Due to Unavailability and Prescription Issues
Penalty
Summary
The facility failed to ensure that medications were available for a resident who was severely cognitively impaired and had multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, non-Alzheimer dementia, malnutrition, anxiety, depression, and psychotic disorder. The resident had a physician's order for tramadol 50 mg twice daily, but the medication was not administered on several occasions due to it being unavailable. Documentation showed missed doses on multiple dates, with reasons including the medication being out of stock and the need for a new prescription. Progress notes indicated that staff recognized the need for a new prescription and attempted to communicate this to the provider, but there was no evidence in the physician progress notes that a new prescription was requested or provided in a timely manner. Facility policy required reordering medications several days in advance and obtaining new prescriptions as needed, but these procedures were not followed, resulting in the resident missing multiple doses of prescribed pain medication.
Significant Medication Error: Crushing of Extended Release Potassium Chloride
Penalty
Summary
A Qualified Medication Aide (QMA) was observed preparing and administering medications for a resident who required her medications to be crushed. During the process, the QMA included a 20 mEq Extended Release (ER) Potassium Chloride tablet among the medications to be crushed. The QMA removed a soft gel vitamin supplement, noting it could not be crushed, but proceeded to crush the remaining medications, including the ER Potassium Chloride tablet, and administered them to the resident with pudding. The QMA later acknowledged that some medications should not be crushed due to their coating and referred to a 'do not crush' list on the medication cart, which specifically included the ER Potassium Chloride tablet. She was unaware at the time of administration that this medication should not be crushed. The resident involved was severely cognitively impaired and had diagnoses including coronary artery disease, hypertension, and malnutrition. A review of the resident's most recent laboratory values showed her potassium level was within normal limits. The facility's 'Medications Not To Be Crushed' list, last revised in December 2022, confirmed that the ER Potassium Chloride tablet should not be crushed due to its extended-release formulation.
Failure to Label Opened Medications on Medication Cart
Penalty
Summary
Surveyors observed that the 100 Hall Medication Cart contained a Basaglar insulin pen and a bottle of liquid fish oil, both belonging to a resident, that were not labeled with the date they were opened. The insulin pen was half full and the fish oil bottle was two-thirds full at the time of inspection. During an interview, the RN confirmed that both medications should have been labeled with the date they were opened, in accordance with facility policy and the medication manufacturer's instructions. The facility's policy requires that a date opened sticker be placed on medications once the original seal is broken, and the Basaglar insulin pen's package insert specifies that it should be discarded 28 days after opening, regardless of remaining content.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store medications, as observed in the 300 Hall Medication Cart and Medication Room. During an inspection, a Lispro insulin pen for a resident was found on the medication cart without an opened-on date. The LPN responsible indicated that the pen was delivered by the pharmacy a month prior and had been refrigerated until use, but it was not labeled when opened. The insulin pen, which is effective for 28 days after opening, was nearly full, suggesting it had not been in use for long. However, the lack of labeling violated the facility's medication storage policy. Additionally, the 300 Hall Medication Storage Room contained an opened vial of TB serum that was not labeled with an opened-on date. The RN present acknowledged that the TB serum should be used within 30 days of opening, but the vial was undated. Several residents had received TB tests using this serum, including tests conducted over a week prior to the inspection. The facility's policy mandates that opened medication containers be dated, which was not adhered to in these instances.
Inappropriate Food Storage
Penalty
Summary
The facility failed to store food appropriately as observed during a kitchen tour. In the walk-in refrigerator, several items were found with expired use-by dates, including five chuck roasts, a cantaloupe, a jar of maraschino cherries, a jar of jelly, and a prepared fruit cup. The Dietary Manager acknowledged that it was the responsibility of the cooks, Assistant Dietary Manager, and herself to ensure outdated foods were discarded, with the refrigerator being checked daily. The weekend cook was responsible for checking the refrigerators on weekends. The facility's policy on food labeling and dating was provided, indicating the procedure for properly labeling and dating food items.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for self-administration of medications, which was observed during a survey. Resident 43 was seen with a medicine cup full of pills on their over-the-bed table without any staff present. The resident identified some of the medications, including a blood thinner and an iron pill, and had a second cup with a reddish fluid. Despite being reminded by an LPN to take their medications, the resident delayed taking a water pill, which remained on the table for several hours. Interviews with staff revealed that there was no completed self-administration assessment for Resident 43, which is required for residents to self-administer medications. The facility's policy mandates an assessment and physician's order for self-administration, but this was not done for Resident 43. The resident's clinical record confirmed the absence of such an assessment, despite the resident being cognitively intact and having a history of various medical conditions.
Failure to Provide Adequate Bathing Services
Penalty
Summary
The facility failed to provide adequate bathing services for two residents, identified as Residents D and E, who were reviewed for Activities of Daily Living. Resident D, who was cognitively intact and had diagnoses including atrial fibrillation, hypertension, and respiratory failure, received only 6 out of 10 scheduled showers or complete bed baths from admission to discharge. The facility's policy required bathing at least twice a week unless otherwise preferred by the resident, but this was not consistently documented or adhered to. Resident E, also cognitively intact with diagnoses including a fracture of the right fibula, anemia, hypertension, and diabetes, was non-compliant with care at times and refused showers. Despite this, the facility's documentation showed that Resident E was given or offered a bath or shower 11 out of 15 times during the review period. The facility's policy required documentation of the type and amount of assistance provided for activities of daily living, but the records indicated inconsistencies in adherence to this policy.
Inadequate Infection Control for Urinary Catheter
Penalty
Summary
The facility failed to adhere to appropriate infection control guidelines for a resident with an indwelling urinary catheter, who had a history of recurrent urinary tract infections (UTIs). During multiple observations, the resident's catheter tubing and drainage bag were seen dragging on the floor or touching the floor while the resident was in their wheelchair. The tubing contained tan-colored debris and cloudy yellow urine, indicating potential contamination. The resident, who was moderately cognitively impaired and had diagnoses including stroke, neurogenic bladder, diabetes, dementia, and hemiplegia, required extensive assistance for transfers, yet was observed with their catheter improperly managed. Interviews with staff, including a CNA and the Therapy Manager, confirmed that the resident required assistance with transfers and that the catheter bag and tubing should not be touching the floor. The facility's Urinary Catheter Care policy, which was reviewed, explicitly stated that catheter tubing and drainage bags should be kept off the floor to prevent infection. Despite this policy, the resident's catheter care was not managed according to these guidelines, contributing to the deficiency noted in the report.
Failure to Follow Hospital Discharge Orders and Verify Admission Weights
Penalty
Summary
The facility failed to adhere to hospital discharge orders and verify admission weights for a resident, identified as Resident D, who was reviewed for hydration and nutrition. Resident D, who was cognitively intact, had diagnoses including atrial fibrillation, hypertension, and respiratory failure. The hospital discharge summary specified that the resident should be weighed daily, with any significant weight changes reported to the physician. The facility was also instructed to maintain a low sodium diet and limit fluid intake. However, the facility did not document daily weights until several weeks after admission, did not follow the prescribed diet and fluid restrictions, and did not address discrepancies between the hospital discharge weight and the facility's admission weight. Interviews with facility staff revealed that the process for transcribing and verifying physician orders was not followed correctly. The Director of Nursing acknowledged that the resident's discharge paperwork indicated daily weighing, which should have been transcribed upon admission. Despite the resident's significant weight decrease, the facility did not investigate the initial weight discrepancy. The facility's policy on notification of change was not adhered to, as there was no documentation of follow-up actions regarding the resident's weight management and dietary needs.
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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