Autumn Ridge Rehabilitation Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Wabash, Indiana.
- Location
- 600 Washington Ave, Wabash, Indiana 46992
- CMS Provider Number
- 155162
- Inspections on file
- 24
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Autumn Ridge Rehabilitation Centre during CMS and state inspections, most recent first.
Surveyors found that required State Agency and Ombudsman contact information was not posted in an accessible manner for residents, including those using wheelchairs. During a Resident Council interview, several residents reported they did not know where to find Ombudsman or State Agency contact details. These residents lived on a floor where they could not independently access the area where the State Agency posting was located, as they were not given the elevator code and had to be accompanied by staff. Observations showed no required postings on their floor, and the only State Agency posting on another floor lacked Ombudsman information and was mounted at a height the AD acknowledged would be difficult for a wheelchair user to see. This conflicted with the facility’s Resident Rights policy and state requirements to post names, addresses, and phone numbers of pertinent State advocacy groups in a form and manner residents can access and understand.
The facility restricted cognitively intact residents on an upper floor from independently accessing the first floor and outdoor patio by using an elevator keypad code not shared with residents and a locked exterior patio door, requiring staff supervision for any movement off the unit. Three residents with diagnoses including anxiety, depression, vitamin D deficiency, heart failure, chronic pain, Parkinson’s disease, and psoriatic arthritis reported feeling like they were in a prison and expressed a strong desire to go outside for fresh air and to access common areas such as the lobby and aquarium. MDS assessments and care plans documented that it was very important for these residents to go outside when weather permitted and that they enjoyed outdoor time, yet the monthly activities calendar lacked outdoor activities. The AD and DON stated that residents could only go outside when staff were available to accompany them, citing corporate direction, elopement concerns for other residents, and a prior elopement, while the Administrator confirmed there was no specific policy for securing the floor or for residents going outside, despite a Resident Rights policy requiring that residents be able to exercise their rights without interference.
A resident who was cognitively intact, frequently incontinent, and required partial to moderate assistance with bathing reported not receiving a shower for over a week, despite having assigned shower days and being willing to bathe at any time. Observations noted greasy, disheveled hair and the same clothing on consecutive days. Facility shower sheets for the month showed missed or undocumented showers on scheduled days, and Point of Care records contained multiple entries for partial bed baths (PBB) and "activity did not occur" without clarity on whether full partial baths or only peri-care were provided. CNAs stated that peri-care was documented as PBB and that blank or incomplete shower sheets could mean missed showers or undocumented care. The DON confirmed that blank shower sheets indicated no shower occurred, and the Administrator acknowledged there was no specific facility policy on showering/bathing beyond a general resident rights policy.
A resident with Parkinson’s disease, dementia, chronic pain, and a documented history of frequent, severe pain repeatedly complained of intense mouth pain and a toothache during breakfast, grimacing, crying out, and declining to eat. An RN walked past without acknowledging the complaints, continued assisting another resident, and, when asked about a dental appointment, did not immediately assess the resident or check for pain interventions. Only after the resident’s distress escalated and the DON was called were Orajel and acetaminophen administered. The resident’s care plans and orders included scheduled and PRN pain medications and nonpharmacologic interventions, and the facility’s pain management policy required pain care based on reported intensity, but staff did not promptly implement these measures when the resident first reported pain.
A resident with multiple chronic conditions was left waiting over 14 minutes for assistance with bed mobility for toileting after requesting help from a CNA, who failed to return. Other residents also reported delays in call light responses, with staff sometimes turning off call lights without providing assistance. Staff and the DON acknowledged that such delays were not acceptable, and the facility lacked a policy on timely call light response.
A resident with upper extremity impairment and multiple medical conditions did not receive timely assistance with nail care, despite repeated requests and visible need. Staff interviews revealed inconsistent practices and lack of clear documentation or policy regarding nail care, resulting in the resident having long, jagged fingernails and struggling to manage personal grooming independently.
The facility did not consistently provide bedtime snacks to residents as ordered by physicians and required by policy. Several residents reported that snacks were only offered intermittently or not at all, with some being told that snacks were unavailable. Staff interviews and pantry observations confirmed that snack supplies were sometimes insufficient, and the process for delivering snacks did not ensure all residents received them as prescribed.
Surveyors observed that staff failed to perform hand hygiene during laundry delivery to multiple residents, despite handling clean laundry, room surfaces, and personal items. Additionally, an LPN did not use required enhanced barrier precautions (gown and gloves) while performing central line care for a resident with multiple infection risks, even though facility policy and signage indicated this was necessary. These lapses occurred despite staff awareness of infection control protocols and the presence of relevant policies and signage.
The facility failed to notify two residents of Medicare non-coverage, lacking the required SNF ABN forms. Staff interviews revealed that the Administrator could not find documentation of completed forms, and the Social Services Director was unaware of the requirement, leading to a gap in the notification process.
A facility failed to provide adequate grooming and dressing assistance to a resident with moderate cognitive impairment, who was observed with unkempt facial hair and clothing with holes. Another resident did not receive timely showers, resulting in greasy hair, despite needing substantial assistance with personal hygiene. Staff interviews revealed no documented refusals of care, indicating a failure in adhering to care plans and documentation practices.
The facility failed to ensure that only qualified staff assisted residents with eating, as an Activity Assistant without full CNA certification was observed assisting a resident. The facility's policy requires licensed and certified personnel for such tasks, and the DON was unaware of the extent of the Activity Assistant's involvement in resident feeding.
Failure to Provide Accessible Posting of State Agency and Ombudsman Contact Information
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required State Agency and Ombudsman contact information was prominently displayed in a location and manner accessible to residents, including those using wheelchairs. During a Resident Council group interview, three residents reported they did not know where to find information for the local Ombudsman or how to contact the State Agency with concerns. One resident stated he could ask the Activities Director for the information. These residents lived on the third floor, where residents were not allowed to access the first floor without staff supervision due to the presence of residents on the third floor who were considered elopement risks. An observation of the third floor revealed no visible postings of State Agency or Ombudsman information. Further observation on the first floor showed that the required State Agency information was posted on the wall next to the elevators, but the posting did not include the Ombudsman’s contact information. During an interview and observation with the Activities Director, the State Agency informational poster was measured at 58 inches from the ground, and the Activities Director acknowledged it would be difficult for a person in a wheelchair to see the information at that height. The Director of Nursing confirmed that residents on the third floor were not given the elevator code and had to be accompanied by staff to go downstairs. The facility’s Resident Rights policy stated that information must be provided to each resident in a form and manner the resident can access and understand, and that the facility must post the names, addresses, and telephone numbers of all pertinent State client advocacy groups, including the State survey and certification agency and the State ombudsman program, among others, as required by 410 IAC 16.23.1-4(j)(3).
Failure to Honor Cognitively Intact Residents’ Right to Free Movement and Outdoor Access
Penalty
Summary
The facility failed to honor residents' rights to self-determination and freedom of movement by restricting cognitively intact residents from independently accessing other areas of the building and the outdoors. During a Resident Council group interview, three residents living on the third floor reported they were prohibited from going to the first floor or the outdoor patio without staff supervision. Barriers included an elevator that required a keypad code, which was not shared with residents, and a locked exterior door to the patio. These restrictions prevented them from visiting common areas such as the first-floor aquarium, the lobby, and the outdoor seating area at will; one resident reported being prevented from going to the lobby to collect cups for coffee the previous evening. All three residents expressed a desire for independent access to facility amenities and the outdoors and stated the facility felt like a prison. Record review showed that each of the three residents was assessed as cognitively intact and without hallucinations, delusions, or behavioral issues. One resident had diagnoses of anxiety, depression, and vitamin D deficiency, and her MDS indicated it was very important for her to go outside for fresh air when weather permitted. Another resident had anxiety, vitamin D deficiency, and psoriatic arthritis, was able to transfer independently in her wheelchair, and her MDS also indicated it was very important for her to go outside for fresh air when weather permitted. The third resident had type 2 diabetes, insomnia, heart failure, chronic pain, and Parkinson's disease, was able to transfer independently in his wheelchair, and his MDS likewise documented that it was very important for him to go outside for fresh air when weather permitted. Care plans for all three residents documented that they enjoyed going outside in good weather and were to participate in activities of their choice, with assistance or reminders as needed. However, the March activities calendar for the third floor contained no scheduled outdoor activities. The AD stated that residents could go outside only when weather permitted and when a staff member was available to accompany them, and that some residents would be fine to go outside unsupervised but corporate required supervision. The DON confirmed that third-floor residents were not given the elevator code because some residents on that floor were elopement risks, that the outside patio door was locked due to a past elopement, and that aides did not have time to take residents downstairs or outside, so they were to contact the AD to do so. The Administrator acknowledged there was no policy for keeping the third floor secured, that residents were not allowed to have the elevator code, that residents had to be supervised to go outside, and that there was no policy for residents going outside, despite a facility Resident Rights policy stating residents must be able to exercise their rights without interference, coercion, discrimination, or reprisal.
Failure to Provide Bathing Assistance per Assessed Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing assistance according to an identified resident’s assessed needs and stated preferences. During a lunch observation, the resident was seen with greasy, disheveled hair. In a Resident Council interview, the resident reported not receiving a shower for over a week, noted that her hair remained greasy and stringy, and that she was wearing the same clothes as the previous day. She stated that her scheduled shower days were Saturdays and Tuesdays, that she had not received showers on those days, that she was willing to shower at any time of day, and that she had never refused a shower. Record review showed the resident had diagnoses including anxiety, depression, and Vitamin D deficiency, and an annual MDS indicated she was cognitively intact, frequently incontinent of bowel and bladder, required partial to moderate assistance for bathing/showering, and that it was very important to her to choose between a shower, bed bath, or sponge bath. Facility shower sheets for March showed a shower on one Saturday and a complete bed bath with hair washed on one Tuesday, but the sheets for two subsequent scheduled shower days were blank except for the resident’s name and date. The DON stated that a blank shower sheet meant no shower had occurred. CNAs reported that blank sheets could mean refusal or that staff forgot to document, and that a sheet without a signature indicated a missed or ignored shower. Point of Care documentation for March showed frequent entries of partial bed baths (PBB) and multiple “activity did not occur” notations on various days, including on and around the resident’s scheduled shower days. CNAs explained that partial bed baths were used to document peri-care and that the electronic record only allowed peri-care to be recorded as a partial bed bath, making it unclear whether entries reflected full partial bed baths or only peri-care. One CNA described a partial bed bath as including face, armpits, and peri-area, while another described it as peri-area and legs, sometimes the back. The Administrator reported there was no facility policy specific to showering/bathing, and the only related written policy provided addressed general resident rights to dignity, well-being, and proper delivery of care.
Failure to Promptly Assess and Manage Resident’s Severe Mouth Pain
Penalty
Summary
The deficiency involves the facility’s failure to promptly assess and manage a resident’s complaints of severe mouth pain during a breakfast meal service. During a dining room observation, the resident repeatedly stated she had a bad toothache, guarded her right lower jaw, grimaced, cried out that it hurt badly, and declined breakfast. An RN walked past the resident after the initial complaint without acknowledging the pain, then sat nearby to assist another resident. Over the next several minutes, the resident continued to vocalize significant pain and insist she needed to go to a dental appointment, while CNAs moved in and out of the dining room and the RN continued assisting another resident. When a CNA asked the RN about the timing of the resident’s dental appointment, the RN shrugged and stated she was not looking, and did not immediately assess the resident or check for available pain interventions. The resident’s crying out intensified, and only after this escalation did the RN ask a CNA to get the DON. The DON then informed the resident that her dental appointment was not that day and indicated staff would obtain Orajel. The RN left the dining room, and Orajel was administered on a disposable mouth sponge, followed by acetaminophen a few minutes later, after the DON propelled the resident toward her room while the resident continued to state she was in horrible pain. The resident’s clinical record showed diagnoses including Parkinson’s disease, dementia, seizures, anxiety, chronic pain, and a pain disorder related to psychological factors. Orders included scheduled and PRN acetaminophen, Tramadol, and PRN Orajel, and a recent MDS documented that the resident was moderately cognitively impaired, frequently in pain, and that pain frequently interfered with sleep and daily activities, with the resident describing her pain as severe. The care plans identified the resident as at risk for pain and called for administering pain medications as ordered, assessing and documenting effectiveness, notifying the physician if pain was unrelieved or worsening, and offering nonpharmacological interventions. Interviews with nursing staff and the DON confirmed that the RN should have assessed the resident when she first complained of mouth pain and that pain complaints should be addressed first, consistent with the facility’s pain management policy requiring necessary care and services to manage pain based on reported intensity.
Failure to Respond Timely to Resident Requests for Assistance with Bed Mobility and Toileting
Penalty
Summary
A deficiency occurred when staff failed to respond promptly to a resident's request for assistance with bed mobility related to toileting needs. During observation, a resident with multiple diagnoses, including COPD, heart failure, acute respiratory failure with hypoxia, hypertension, and type 2 diabetes, was seen attempting to use a urinal while lying in bed and requested help from a CNA to be repositioned. The CNA acknowledged the request but did not return, leaving the resident to manage alone for over 14 minutes until another CNA entered and provided the needed assistance. The resident's care plan indicated a need for assistance with activities of daily living, including bed mobility and toileting. Additional interviews revealed that other residents also experienced delays in having their call lights answered, with staff sometimes turning off call lights without providing assistance and returning only after a significant wait. Staff interviews confirmed that residents should not have to wait extended periods for assistance, and the DON stated that it was not acceptable for residents to wait 20 or more minutes for their call lights to be answered. The administrator indicated there was no policy regarding timely response to call lights.
Failure to Provide Timely Nail Care Assistance
Penalty
Summary
A deficiency was identified when a resident, admitted with a history of left femur fracture, muscle weakness, anxiety, depression, hypertension, and mood disorder, did not receive adequate assistance with nail care. The resident, who was cognitively intact but had upper extremity impairment on one side, reported that no one had offered to cut his fingernails since admission. Multiple observations over several days showed the resident with long, jagged, and sharp fingernails, and he repeatedly stated that he had requested assistance from staff, but his nails remained untrimmed. Interviews with CNAs and the DON revealed inconsistent practices regarding nail care, with staff indicating that nails were cut as needed or upon request, typically on shower days. Documentation of refusals was unclear, and there was no established policy on nail care or grooming. The resident ultimately received partial assistance but continued to struggle with nail care due to his impairment, and fingernail clippers were left at his bedside for self-use.
Failure to Consistently Provide Bedtime Snacks as Ordered
Penalty
Summary
The facility failed to consistently provide bedtime snacks to all residents as ordered by their physicians and as required by facility policy. During a resident council meeting, several residents reported that bedtime snacks were only offered about half the time. Individual interviews with residents revealed that some had never received a bedtime snack, while others received them only occasionally or when snacks were available. One resident specifically mentioned that staff told her they were out of snacks, and she had only received her snack once in two weeks. Another resident, who took medications at bedtime, stated he would like a snack but had never been offered one. Clinical record reviews showed that all six residents involved had current physician orders for bedtime snacks, and most were cognitively intact or only mildly impaired, requiring varying levels of assistance with eating and mobility. Diagnoses among these residents included conditions such as fractures, heart failure, diabetes, chronic obstructive pulmonary disease, stroke, cancer, and mental health disorders. Despite their medical needs and dietary orders, the residents did not consistently receive the prescribed bedtime snacks. Staff interviews indicated that snacks were supposed to be offered when residents were put to bed, but there had been instances where the third floor ran out of snacks. Observations of the snack pantry revealed a limited supply of items, such as Gatorade and fig cookie bars. The dietary manager and DON confirmed the process for delivering and storing snacks, but the practice did not ensure that all residents received their snacks as ordered. Facility policy required that snacks be available between meals and that a bedtime snack be offered to all residents according to their diet orders, which was not consistently followed.
Failure to Follow Infection Control Practices During Laundry Delivery and Central Line Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during the delivery of laundry services. Observations over several days revealed that a laundry aide repeatedly entered and exited multiple resident rooms, handling clean laundry, closet doors, drawers, and hangers without performing hand hygiene at any point during the process. The aide acknowledged in an interview that hand hygiene was required after touching surfaces such as knobs and dressers, and the facility's own policy specified that hand hygiene should be performed before removing or touching clean laundry. Supervisory staff confirmed that the majority of residents received laundry services from the facility, indicating the widespread potential for cross-contamination. Additionally, the facility failed to utilize enhanced barrier precautions (EBP) during care for a resident with a central line, who was at higher risk for infection. The resident's clinical record included diagnoses such as surgical aftercare, rectal abscess, malignant neoplasm of the cervix, and Enterococcus infection, and she was receiving regular central line flushes as ordered by a physician. Despite the presence of EBP signage and a PPE cart in the resident's room, and facility policy requiring gown and gloves for high-contact care activities involving central lines, an LPN performed a central line flush without donning the required PPE. The clinical record and care plan also lacked documentation of EBP interventions for this resident. Interviews with staff, including the LPN, DON, and other personnel, confirmed that EBP was required for residents with invasive devices such as central lines, and that signage and PPE carts were in place to support compliance. However, the observed failure to use PPE during high-contact care activities, as well as the lack of care plan interventions for EBP, demonstrated a breakdown in adherence to infection control protocols. Facility policies provided clear guidance on both hand hygiene and EBP, but these were not consistently followed during the observed events.
Failure to Provide Medicare Non-Coverage Notification
Penalty
Summary
The facility failed to provide necessary notifications of Medicare non-coverage for two residents who were under Medicare Part A Skilled Services. Resident 24 was admitted to the facility and continued to stay beyond the last covered day of Part A services, which was on 5/24/24. Similarly, Resident 138 remained in the facility after the last covered day of Part A services on 1/16/24. In both cases, the clinical records lacked the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN), indicating a failure to inform the residents or their representatives about the end of Medicare coverage and potential financial liability. Interviews with facility staff revealed gaps in the notification process. The Administrator was unable to find documentation that the SNF ABN forms were completed or mailed to the residents' representatives. The Social Services Director, who was responsible for notifying residents' representatives when skilled services were ending, was unaware of the requirement to fill out the SNF ABN form. Although she attempted to notify representatives by phone and mailed forms for their decision, she could not provide documentation of these discussions or proof of mailing. The facility also lacked a specific policy regarding Beneficiary Protection Notification, contributing to the oversight.
Deficiencies in Grooming and Showering Assistance
Penalty
Summary
The facility failed to provide adequate grooming and dressing assistance to a resident, identified as Resident 1, who was observed multiple times with unkempt facial hair and wearing clothing with holes that exposed her skin. Despite the resident's moderate cognitive impairment and need for assistance with activities of daily living (ADLs), as indicated in her care plan, staff did not document any refusals of care or make necessary adjustments to her clothing. Interviews with staff, including CNAs and the DON, revealed that there were no records of the resident refusing grooming or dressing assistance, and staff were expected to offer help with clothing adjustments and shaving as needed. Another resident, identified as Resident 26, did not receive timely showers, resulting in greasy hair over several days. The resident's care plan required substantial assistance with showering and personal hygiene, with a schedule of two showers per week. However, documentation showed gaps in showering and no records of refusals during these periods. Interviews with CNAs and the DON confirmed that there were no documented refusals or full bed baths provided during the time frames when showers were missed. The facility's failure to adhere to care plans and document refusals of care contributed to the deficiencies observed. The lack of proper grooming and timely showers for these residents highlights a failure in providing necessary assistance with ADLs, as required by their care plans. The facility's documentation practices and staff adherence to care protocols were insufficient to meet the residents' needs.
Unqualified Staff Assisting with Resident Feeding
Penalty
Summary
The facility failed to ensure that only qualified staff assisted residents with eating during mealtime observations. Specifically, an Activity Assistant, who had not yet passed the written portion of her CNA certification, was observed assisting a resident with eating. The facility's policy requires that only licensed and certified personnel are permitted to assist residents with eating, and the Activity Assistant had only passed her skills test, not the full certification. The Director of Nursing (DON) was uncertain about how long the Activity Assistant had been assisting residents with eating without full certification and was not generally present during mealtimes to monitor the situation. The facility's policy allows individuals who have completed a Nurse Aide Training Program to work as a Nurse Aide for up to 120 days without full certification, but the Activity Assistant's role in assisting with eating was not compliant with this policy. The facility's failure to adhere to its policy resulted in unqualified staff assisting residents with eating.
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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