Avalon Springs Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Valparaiso, Indiana.
- Location
- 2400 Silhavy Road, Valparaiso, Indiana 46383
- CMS Provider Number
- 155795
- Inspections on file
- 25
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Avalon Springs Health Campus during CMS and state inspections, most recent first.
A resident requiring maximum assistance for activities of daily living was left in bed with a saturated incontinence brief and wet sheets for several hours, despite care plan interventions to provide toileting assistance at regular intervals. Staff confirmed the delay in care, and documentation showed the resident had a history of recurrent UTIs and was always incontinent of bowel and bladder.
Staff failed to use required PPE, including gowns, and did not perform hand hygiene after glove removal while providing care to two residents on Enhanced Barrier Precautions (EBP) for urinary catheters and intravenous lines. Care plans and facility policy specified the need for gowns and gloves during high-contact care, but staff were observed omitting gowns and not completing hand hygiene, even after handling soiled materials.
A resident with cognitive impairment and a history of falls was found without bolsters on his bed, despite their inclusion in his care plan. The resident experienced multiple falls while attempting to reposition himself using a trapeze bar. Interviews confirmed the absence of bolsters, indicating a failure to implement necessary fall prevention measures.
A facility failed to ensure a resident had a Physician's Order to self-administer medication. The resident, with multiple health conditions and moderate impairment in decision-making, was observed with nasal saline spray on their overbed table without an order for self-administration. Interviews with an LPN and the DON confirmed the absence of necessary orders.
A resident with heart failure and hypertension was not properly monitored for low heart rates while on carvedilol. Despite multiple instances of heart rates below 55 bpm, the physician was not notified, and the medication was administered without parameters for withholding it. The resident was hospitalized twice, and the dosage was adjusted, but the facility failed to follow its policy for physician notification.
A resident's privacy was compromised when an RN left the electronic medication record (EMR) open and unlocked in the hallway during a medication pass. The RN was observed disconnecting intravenous medication and left the computer screen accessible, displaying the resident's personal information. The RN later acknowledged the oversight, and the Director of Nursing confirmed the screen should have been locked.
The facility failed to involve two residents in decisions about their care, including new medications and care planning conferences. One resident was not informed about new medications and lab tests, while another was not invited to care plan conferences and was not kept informed of medication changes. The Director of Nursing and Administrator acknowledged these oversights.
The facility failed to administer blood pressure medications according to prescribed parameters for two residents. One resident received Hydralazine and Metoprolol despite blood pressure and heart rate being below specified limits. Another resident was given Carvedilol without parameters, even when heart rate was below 55 bpm. The DON acknowledged the issue, but no policy was provided.
The facility failed to properly document and manage urinary catheters for three residents. A resident with a neurogenic bladder had urine output recorded only during day shifts, contrary to the care plan. Another resident's catheter bag was observed on the floor, and urine output was not documented every shift. A third resident's urine output was recorded less frequently than ordered. The DON confirmed the documentation issues.
A facility failed to monitor the nutritional intake and weight of a resident with significant weight loss. The resident, with multiple health issues, was at risk for malnutrition. Despite a care plan, weekly weights were not documented as recommended, and there were numerous instances of undocumented supplement and meal consumption. Interviews confirmed these deficiencies.
A facility failed to maintain a PICC line for a resident, leading to a deficiency in IV fluid administration. The resident reported that the PICC line bandage had not been changed since admission, and observations confirmed the bandage was unchanged with dried blood visible. The care plan required IV site care, and physician's orders specified dressing changes every five days, but the Treatment Administration Record showed missed changes. The Director of Nursing could not provide additional information, and the facility's catheter care policy was not followed.
A resident with multiple respiratory and cardiac conditions was observed receiving oxygen therapy at an incorrect flow rate, set at 2.5 liters per minute instead of the physician-ordered 3 liters per minute. The error was identified and corrected by an LPN, and the DON was informed but had no further information.
A resident with multiple medical conditions, including spinal stenosis and opioid use, experienced unmanaged pain despite being on Fentanyl and Norco. The facility failed to administer diclofenac gel or attempt non-pharmacological interventions as per the resident's care plan. The resident was not informed about the availability of the gel, which was only applied after the issue was highlighted.
A facility failed to maintain accurate clinical records for a resident with multiple diagnoses, including dysphagia, who was receiving nutrition through a peg tube. The resident's medications were administered both orally and through the tube, despite physician's orders specifying oral administration only. An RN confirmed administering medications through the peg tube without a physician's order, while the DON noted a change in administration route following the resident's decline.
The facility failed to implement infection control guidelines during wound treatment and medication administration for two residents. A hospice CNA and RN did not use enhanced barrier precautions (EBP) while treating a resident with pressure ulcers, failing to don gowns and change gloves between treatments. Another RN did not follow hand hygiene protocols during a medication pass for a resident with a PICC line, neglecting to wash hands between glove changes and allowing IV tubing to touch the floor. The facility's policies on dressing changes, EBP, and hand hygiene were not adhered to.
A resident with a history of stroke and cellulitis experienced worsening edema and wheezing, but the facility failed to follow up with the physician after sending faxes. Despite the facility's policy requiring phone notification if no response was received within 12 hours, this was not done. The physician assessed the resident two days later and adjusted the medication regimen.
The facility failed to provide proper care for PICC lines for three residents, including lack of documentation and assessments upon admission, incorrect administration of flushes, and missed dressing changes. The DON was unable to locate necessary documentation for the PICC line care.
The facility failed to ensure staff were aware of Enhanced Barrier Precautions (EBP) and did not use correct PPE for residents with PICC lines. Observations revealed missing EBP signs and carts, and staff interviews indicated a lack of training. CNA 3 and LPN 2 did not follow EBP protocols, such as donning gowns and changing gloves, potentially affecting residents with conditions like cellulitis.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A resident who required maximum to dependent care for activities of daily living did not receive timely incontinence care. Observations showed that the resident was left in bed with a saturated incontinence brief and wet sheets, with the last incontinence care documented at 7:30 a.m. Staff acknowledged the resident was incontinent of a large amount of urine, and the resident had been waiting for assistance to get out of bed after breakfast. The resident's care plan indicated she should be offered toileting assistance upon rising, before and after meals, and before bedtime, and that she was always incontinent of bowel and bladder and unable to recognize the need to void. Record review revealed the resident had a history of metabolic encephalopathy, multiple urinary tract infections, and sepsis, with recurrent UTIs noted in a recent physician's note. The facility did not have a specific policy for how often residents should be checked for incontinence, but the DON stated residents were usually checked before and after meals and before bedtime. The Indiana State Department of Health Nurse Aide Curriculum recommends frequent monitoring and perineal care for residents with incontinence. The failure to provide timely incontinence care was observed and confirmed by staff.
Failure to Ensure Proper PPE and Hand Hygiene During Enhanced Barrier Precautions
Penalty
Summary
Staff members failed to use appropriate Personal Protective Equipment (PPE) when providing care to residents requiring Enhanced Barrier Precautions (EBP). In one instance, a CNA assisted a resident with a urinary catheter and intravenous line into the bathroom while only wearing gloves and not a protective gown, despite signage and care plans indicating EBP was required. The Director of Nursing observed this lapse and confirmed that a gown should have been worn. The CNA exited the bathroom with a soiled brief in a clear garbage bag for disposal, still without the required gown. In another case, a CNA assisted a resident with an indwelling urinary catheter who required EBP, but only wore gloves and a mask, omitting the protective gown. The CNA was also unsure which resident required EBP and, after changing a urinary drainage leg bag, exited the room still wearing gloves, removed them in the hallway, and failed to perform hand hygiene before proceeding to the nurses' desk. Both residents involved had diagnoses including urinary tract infections and required EBP for high-contact care, as documented in their care plans. Facility policies required the use of gowns and gloves for EBP and mandated hand hygiene before and after resident contact and glove removal.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident with a history of multiple falls. Resident C, who was cognitively impaired and required substantial assistance with daily activities, was observed without bolsters on his bed, despite the care plan indicating their necessity. The resident had experienced four falls over the past two months, with incidents occurring on 1/6/25, 2/9/25, 2/11/25, and 2/26/25. These falls were associated with the resident attempting to reposition himself in bed using a trapeze bar, which resulted in him slipping and falling out of bed. Interviews with the nursing staff and the Director of Nursing revealed that bolsters, which were part of the resident's care plan to prevent falls, were not present on the resident's bed. The Director of Nursing confirmed the absence of bolsters and had no additional information regarding their omission. This oversight in implementing the care plan's fall prevention measures contributed to the resident's repeated falls, highlighting a deficiency in ensuring the safety and adequate supervision of residents at risk for accidents.
Lack of Physician's Order for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident had a Physician's Order to self-administer their own medications. During multiple observations, a resident was seen with a bottle of nasal saline spray on their overbed table, but there was no order for the resident to self-administer the nasal spray. The resident's medical record indicated diagnoses including heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure. The resident was moderately impaired for daily decision-making and received oxygen therapy. Despite these conditions, there was no care plan in place for self-administration of medications, and the Physician's Orders did not include permission for the resident to self-administer the nasal spray. Interviews with an LPN and the Director of Nursing confirmed the absence of such orders.
Failure to Notify Physician of Abnormal Vital Signs
Penalty
Summary
The facility failed to notify a physician of abnormal vital signs for a resident who was receiving carvedilol for hypertension. The resident, who was cognitively intact and dependent on staff for toileting and transfers, had a history of heart failure, hypertensive heart disease, and diabetes mellitus. The resident's heart rate was documented below 55 beats per minute on multiple occasions in October and November 2024, with no evidence that the physician was informed of these abnormal readings. Despite the low heart rates, the medication was administered without any parameters in place to guide when it should be withheld. The resident was admitted to the hospital twice during this period, and upon return, the carvedilol dosage was adjusted due to low heart rate. However, there was still no documentation of physician notification regarding the low heart rates. The facility's policy required that physicians be notified of any changes in condition or diagnostic results, but this was not adhered to in this case. The Director of Nursing was informed of the oversight, but no additional information was provided to address the lack of physician notification.
Resident Privacy Breach Due to Unlocked EMR
Penalty
Summary
The facility failed to maintain a resident's privacy concerning their electronic medication record (EMR) during a medication pass. On November 21, 2024, at 12:21 p.m., a registered nurse (RN 1) was observed disconnecting intravenous medication for a resident. During this process, the RN left the EMR open and unlocked on a computer in the hallway, making the resident's medications and personal information visible. The RN gathered supplies from the 300 Hall cart and proceeded to the resident's room, leaving the computer screen accessible. At 12:28 p.m., the RN returned to the 300 Unit Nurses' Station, and the computer screen remained open and visible in the hallway. In an interview conducted at 12:28 p.m. on the same day, RN 1 acknowledged not realizing the screen was left open and confirmed that it should always be locked when not in use. The Director of Nursing, interviewed on November 25, 2024, at 2:57 p.m., also indicated that the computer screen should have been locked when the nurse walked away.
Failure to Involve Residents in Care Decisions and Planning
Penalty
Summary
The facility failed to ensure that residents were involved in decisions about their care, specifically regarding new medications and participation in care planning conferences. Resident 38 was not informed about new medications, laboratory tests, or treatments, despite having multiple diagnoses including heart disease and COPD. The resident's daughter was notified of changes, but there was no documentation that the resident was informed. The Director of Nursing acknowledged that the resident should have been notified of these changes. Similarly, Resident 49 was not invited to or informed about care plan conferences and was not kept informed of medication changes. This resident had several health issues, including a knee replacement and chronic kidney disease. Although the resident's wife was informed of new medication orders, there was no documentation that the resident was notified. The Administrator mentioned that the resident was invited to the care plan conference, but the family did not want the resident to attend, and no separate conference was held for the resident.
Failure to Administer Blood Pressure Medications According to Parameters
Penalty
Summary
The facility failed to administer blood pressure medications according to the prescribed parameters for two residents, leading to deficiencies in medication management. Resident 38, who had diagnoses including heart disease and congestive heart failure, was prescribed Hydralazine and Metoprolol with specific parameters to hold the medication if the systolic blood pressure was less than 110 or the heart rate was less than 60. However, the Medication Administration Record (MAR) indicated that these medications were administered on multiple occasions when the resident's blood pressure and heart rate were below the specified parameters. Interviews with staff revealed that the medications were not consistently held as ordered by the physician. Resident 5, who was admitted with conditions such as heart failure and hypertensive heart disease, was prescribed Carvedilol without specific parameters for holding the medication. The MAR showed that the medication was administered even when the resident's heart rate was documented below 55 beats per minute on several occasions. Despite a physician's order to decrease the dosage due to low heart rate, the medication continued to be administered without appropriate monitoring or parameters in place. The Director of Nursing acknowledged that medications should be held if the heart rate was in the 40s, but no policy was provided to guide staff on this matter. The report highlights a lack of adherence to physician orders and inadequate monitoring of vital signs before administering medications, which could potentially lead to adverse effects for the residents. The facility's failure to ensure medications were administered according to the prescribed parameters and the absence of a clear policy for holding medications based on vital signs contributed to the deficiencies identified during the survey.
Deficiencies in Urinary Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure proper documentation and handling of urinary catheters for three residents. Resident 6, who had a neurogenic bladder and an indwelling urinary catheter, had a care plan requiring urinary output to be recorded every shift. However, documentation showed that urine output was only recorded during day shifts over a 30-day period, despite the requirement for 12-hour shift documentation. The Director of Nursing confirmed that urine output should have been documented every shift. Resident 216, with chronic kidney disease and an indwelling urinary catheter, was observed with a catheter bag resting on the floor, which was not addressed in the care plan. The resident's urine output was also not documented every shift as required. Similarly, Resident 13, who had an indwelling urinary catheter and a history of sepsis and urinary tract infections, had urine output documented less frequently than the physician's order of three times per day. The Director of Nursing acknowledged the lack of proper documentation but did not provide further information.
Failure to Monitor Nutritional Intake and Weight
Penalty
Summary
The facility failed to adequately monitor the nutritional intake and weight of a resident with significant weight loss. The resident, who had multiple diagnoses including heart disease, congestive heart failure, COPD, and acute respiratory failure, was identified as being at risk for malnutrition. Despite a care plan that included providing a therapeutic diet, supplements, and regular monitoring, the facility did not document weekly weights as recommended by a Registered Dietitian. The resident experienced a significant weight loss of 8.2% over 30 days, and the dietitian had suggested weekly weight checks for four weeks, which were not completed. Additionally, there were numerous instances where the consumption of prescribed nutritional supplements and meals was not documented. The med pass supplement was not recorded as administered on several specific dates, and meal consumption logs were incomplete for breakfast, lunch, and dinner on various dates. Interviews with the Director of Nursing confirmed the incompleteness of meal and supplement consumption records, as well as the failure to complete weekly weight checks.
Failure to Maintain PICC Line for Resident
Penalty
Summary
The facility failed to maintain a peripherally inserted central catheter (PICC) line for a resident, leading to a deficiency in the administration of intravenous (IV) fluids. The resident, who had a history of wound infection, diabetes, and other health issues, reported that the PICC line bandage had not been changed since his admission to the facility. Observations confirmed that the bandage was unchanged, with brown dried blood visible under the clear tegaderm, and one of the ports was not functioning. The resident's care plan required IV site care as ordered, and physician's orders specified that the PICC dressing should be changed every five days. The Treatment Administration Record (TAR) for November 2024 showed that the PICC line dressing change was not documented as completed on the specified dates of 11/12 and 11/17/24, with the first recorded change occurring on 11/22/24. The Director of Nursing was unable to provide additional information regarding the missed dressing changes. The facility's catheter care policy required dressing changes at specified intervals or when compromised, but this was not adhered to, resulting in a failure to prevent potential catheter-related infections.
Oxygen Flow Rate Discrepancy for Resident
Penalty
Summary
The facility failed to ensure that oxygen concentrators were set at the correct flow rate for a resident receiving oxygen therapy. During multiple observations, the resident was found wearing oxygen via nasal cannula with the concentrator set at 2.5 liters per minute, despite the physician's order specifying a continuous flow of 3 liters per minute. The resident, who had diagnoses including heart disease, congestive heart failure, acute pulmonary edema, chronic obstructive pulmonary disease (COPD), and acute respiratory failure, was moderately impaired in daily decision-making and required oxygen therapy as part of her care plan. The discrepancy in the oxygen flow rate was identified by an LPN, who adjusted the setting to the correct rate. The Director of Nursing was informed of the issue but had no additional information to provide.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to manage and monitor the pain of a resident, identified as Resident 157, who was observed experiencing significant discomfort. On two separate occasions, the resident was seen grimacing and complaining of back pain, which he rated as 7 out of 10 in severity. Despite being on a Fentanyl patch and Norco, the resident reported that his pain was not well controlled and expressed a need for new or adjusted pain medications. The resident's medical history included conditions such as cellulitis, heart failure, chronic kidney disease, atrial fibrillation, depression, spinal stenosis, and opioid use. The resident's pain care plan aimed to maintain pain at a tolerable level through various interventions, including medication administration and non-pharmacological methods. However, the facility did not adequately implement these interventions. The Medication Administration Record indicated that the resident could receive diclofenac gel as needed, but it had not been administered, and there was no evidence of non-pharmacological interventions being attempted. An RN acknowledged that the resident was not informed about the availability of the diclofenac gel, which was only applied after the issue was raised. The facility's policy on pain management emphasized educating residents about available interventions and evaluating their effectiveness, but these steps were not followed, leading to the deficiency.
Failure to Maintain Accurate Medication Administration Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident regarding the administration route of medications. The resident, who had multiple diagnoses including colitis, dehydration, congestive heart failure, dementia, Alzheimer's disease, heart disease, Parkinson's disease, and dysphagia, was receiving nutrition through a peg tube. The resident's daughter reported that medications were administered both orally and through the tube. However, the physician's orders specified oral administration for Carbidopa-Levodopa and Pepcid, with no order for administration through the peg tube. An RN confirmed administering medications through the peg tube without a physician's order, while the Director of Nursing indicated that the resident's medications were initially given orally but were later administered through the peg tube following the resident's decline.
Infection Control Deficiencies in Wound Care and Medication Administration
Penalty
Summary
The facility failed to implement infection control guidelines during wound treatment and medication administration for two residents. In the first instance, a hospice CNA and RN did not use enhanced barrier precautions (EBP) while providing care to a resident with pressure ulcers. They did not don gowns as required, and the RN failed to change gloves between treating different wounds, using the same gloves to apply cream and dress the ulcers. The resident's room had a sign indicating EBP was necessary, but the staff were unaware of this requirement. The Director of Nursing confirmed that a gown was required for such procedures. In the second instance, an RN did not follow proper hand hygiene protocols during a medication pass for a resident with a peripherally inserted central catheter (PICC) line. The RN did not wash her hands before putting on gloves, failed to perform hand hygiene between glove changes, and allowed IV tubing to touch the floor while administering medication. Although the resident was under EBP, the RN did not wear a gown, believing it was not necessary for PICC line medication administration. The Director of Nursing had no additional information to provide regarding this incident. The facility's policies on dressing changes and EBP were not adhered to during these observations. The dressing changes policy required handwashing and glove changes between steps, which were not followed. The EBP policy mandated the use of gowns and gloves during high-contact care activities for residents with chronic wounds or indwelling medical devices, which was not implemented in these cases. The hand hygiene policy also required handwashing before and after glove use, which was not consistently practiced by the staff.
Failure to Follow Up on Physician Notification for Change in Condition
Penalty
Summary
The facility failed to follow up on a notification of a change in condition with a resident's physician for one of the residents reviewed. The resident, who had a history of stroke and cellulitis, exhibited signs of edema in both lower legs and had gained weight over two days. The resident mentioned taking an extra dose of Lasix when experiencing edema. The facility faxed the physician with the assessment information and notified the resident and family, but there was no documentation of a response from the physician or any follow-up phone call regarding the condition changes. Further documentation indicated that the resident complained of wheezing, and a fax was again sent to the physician. Despite the worsening edema and the resident's complaints, there was no record of a physician's response to the faxes sent on consecutive days. The facility's policy required phone notification to the provider if there was no response to a fax within 12 hours, but this protocol was not followed. The physician eventually assessed the resident two days later, noting significant edema and adjusting the medication regimen.
Deficient PICC Line Care in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards of practice in the care of peripherally inserted central catheters (PICC lines) for three residents, identified as Residents E, F, and C. For Resident E, the facility did not document the presence of a PICC line upon admission, nor did it assess the insertion site, measure the catheter length, or the arm circumference. The LPN administered a flush with 10 cc's of normal saline instead of the ordered 5 cc's. The Director of Nursing (DON) was unable to locate any assessments or documentation regarding the PICC line care upon admission. Resident F's care was similarly deficient, with no documented assessment of the PICC site, catheter length, or arm circumference upon admission. The facility failed to perform scheduled dressing changes and measurements, as indicated by the Medication Administration Record. The DON acknowledged the lack of documentation and was unable to provide further information regarding the PICC line care. For Resident C, the facility did not document the location of the PICC line, assess the site, or measure the catheter and arm circumference upon admission. Scheduled dressing changes and assessments were not consistently documented, and the MAR indicated that the PICC line site was not assessed for signs of complications. The DON confirmed the absence of documentation and was unable to provide additional information on the PICC line care for the residents involved.
Inadequate EBP Implementation and PPE Use
Penalty
Summary
The facility failed to ensure that staff were aware of which residents were under Enhanced Barrier Precautions (EBP) and did not use the correct Personal Protective Equipment (PPE) when providing care to a resident under EBP. During an initial tour, it was observed that there were no signs on the entry doors of residents with PICC lines, indicating they were on EBP. Additionally, there were no carts outside the rooms to indicate the residents' EBP status. Interviews with staff revealed a lack of awareness and training regarding EBP, with some staff unsure about the precautions and others indicating that signs and isolation carts should be present but were not. The report highlights specific instances where staff failed to adhere to EBP protocols. For example, CNA 3 assisted Resident F, who had a PICC line, without initially donning a gown, as required by EBP. The CNA had to leave the room to retrieve gowns, indicating a lack of preparedness and awareness. Similarly, LPN 2, while tending to Resident F's PICC line, initially failed to don a gown and mask and did not change gloves or wash hands after touching contaminated surfaces, which was against the facility's handwashing policy. The facility's infection control nurse admitted that there had not been comprehensive staff education on EBP, and staff had not signed off on any training. The facility's policies on EBP and handwashing were not being followed, as evidenced by the observations and interviews. This deficiency had the potential to affect residents with PICC lines, such as Residents E and F, who were diagnosed with conditions like cellulitis and required intravenous antibiotics.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
