Beaumont Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Anderson, Indiana.
- Location
- 1345 N Madison Ave, Anderson, Indiana 46011
- CMS Provider Number
- 155005
- Inspections on file
- 40
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 22 (1 serious)
Citation history
Health deficiencies cited at Beaumont Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Multiple residents with significant mobility impairments and obesity were not provided showers or bed baths according to their documented preferences and scheduled care in their MDS assessments and ADL care plans. Facility shower sheets and electronic documentation showed repeated missed bathing on designated days over several months for residents who preferred specific days and time frames for showers or bed baths. Some residents reported going extended periods without bathing and one reported frequently missing showers and attending physician appointments feeling unclean. Staff interviews acknowledged that showers were not always given as scheduled and that staffing absences contributed to the issue, while facility policy required prescribed orders to be followed or reasons for noncompliance to be documented, which was not consistently done.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report notes insufficient safety measures and supervision but does not specify the individuals involved or the exact hazards present.
The facility did not provide up-to-date education on influenza vaccines or obtain current vaccination consents for several residents. In multiple cases, education materials were outdated, consents were missing or not current, and documentation of vaccine administration was incomplete. Staff confirmed that current CDC information was not used and required consents were not consistently obtained.
The facility failed to ensure shift-to-shift narcotic reconciliation for six medication carts, including the Rehab cart and carts for the 200, 300, 400, and 500 halls. Observations revealed missing reconciliations on various shifts throughout June 2024. Interviews with the Family Tree Unit Manager and DON indicated that the expected procedure of signing the Controlled Substances Check Form was not followed, risking drug diversion.
The facility failed to implement effective Quality Assurance and Performance Improvement (QAPI) measures to address the issue of nurses not signing in and out for narcotic medication reconciliation at shift changes. The Director of Nursing (DON) initiated a Performance Improvement Plan (PIP) but lacked audit tools and documentation to support its implementation. Despite some reviews being conducted, the absence of a 'Clean Fridays' tool and evidence of corrective actions led to the deficiency.
Three residents reported unresolved dietary grievances, including missed meals before dialysis, repeated receipt of disliked foods, and inadequate portion sizes. Despite raising these issues with staff, the facility failed to document or address the concerns, violating its grievance policy.
A facility failed to report an allegation of abuse involving a resident with severe cognitive impairment. A CNA reported that an RN was rough with the resident, including yelling and forcefully handling her, causing distress. Despite the facility's policy requiring immediate reporting of such allegations, the Administrator did not report the incident to the IDOH, believing it was not abuse.
A facility failed to implement a safety plan for a resident with dementia and a history of wandering, resulting in the resident being hit and choked by another resident. Despite the facility's awareness of the resident's behavior, 15-minute monitoring checks were not conducted, leading to two altercations within 24 hours. Staff interviews confirmed the lack of monitoring, and the facility's policies were not effectively followed to ensure safety.
The facility failed to complete Quarterly MDS assessments on time for four residents, with delays ranging from 1 to 13 days. The MDS Coordinator acknowledged the late completions, despite using the RAI manual for guidance. The RAI manual requires completion within 14 days after the ARD.
A facility failed to submit a resident's MDS assessment on time, resulting in a deficiency. The resident, diagnosed with sepsis, congestive heart failure, and diabetes mellitus, was discharged, and their Discharge MDS assessment was completed on time but transmitted 68 days late. The MDS Coordinator, who shared transmission duties with an offsite consultant, missed the assessment in error. The RAI manual requires transmission within 14 days of completion.
The facility failed to conduct timely care plan meetings for three residents on a secured dementia unit, despite multiple MDS assessments. The last documented meetings for these residents were in January 2024 or earlier, contrary to the facility's policy requiring meetings within seven days of MDS completion. The Dementia Unit Manager cited scheduling difficulties due to the new MDS frequency.
A facility failed to complete physician-ordered wound care for a resident with a foot abrasion. The treatment administration record showed missing entries for several dates, with no documentation explaining the omissions. Interviews with staff confirmed that the treatments should have been completed as ordered, and the facility's policy requires documentation of any deviations.
A facility failed to provide wound care as ordered for a resident with a pressure injury, resulting in a deficiency. The resident had a physician's order for specific wound care treatments, which were not consistently completed, as evidenced by missing documentation and unchanged dressings. Interviews with staff confirmed the treatments were not administered as required, contrary to the facility's policy on pressure ulcer care.
The facility failed to follow physician orders for oxygen administration for two residents with respiratory conditions. One resident with COPD had their oxygen concentrator set above the prescribed 2-3 liters per minute, while another resident with COPD and emphysema had their concentrator set above the prescribed 2 liters per minute. Staff interviews confirmed the expectation to adhere to physician orders, which was not met.
The facility failed to properly label and dispose of insulin vials, leading to the use of expired insulin for residents. Observations revealed expired and undated insulin vials on two medication carts. LPNs were either unaware of the correct expiration period or did not date the vials upon opening, contrary to facility policy.
The facility did not follow infection prevention and control procedures during wound care for two residents under Enhanced Barrier Precautions (EBPs). An LPN and a CNA performed wound care without wearing gowns, despite visible EBP signage indicating the need for gown and glove use. Interviews confirmed that EBPs should have been followed, and the facility's policy required gown and glove use for high-contact activities like wound care.
A resident's phone was reported missing after a hospital transfer, and the facility failed to report the alleged misappropriation to the Indiana Department of Health within the required timeframe. The phone was later tracked to a CNA's residence, leading to a police investigation. The facility did not report the incident until 18 days after the initial allegation.
The facility failed to thoroughly investigate an allegation of misappropriation of a resident's phone. The investigation was delayed, lacked detailed communication, and did not include interviews with all relevant staff members. The phone was later tracked to a CNA's residence, but the facility did not provide updates to the resident or their representative.
Failure to Provide Scheduled and Preferred Bathing for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document bathing assistance according to residents’ assessed preferences and scheduled care. Multiple residents with significant physical impairments and obesity, including paraplegia and hemiplegia, had care plans and MDS assessments specifying preferred days and time frames for showers or bed baths. For Resident B, who had paraplegia and morbid obesity, the admission MDS and ADL care plan indicated a preference for bed baths on Tuesdays and Fridays between 2:00 p.m. and 10:00 p.m., yet shower sheets and Documentation Survey Reports showed numerous missed scheduled bed baths across January, February, and March 2026. Resident C, with morbid obesity and paraplegia, had an admission MDS and ADL care plan indicating a preference for showers on Tuesdays and Fridays between 6:00 a.m. and 2:00 p.m. Facility records showed that several of these scheduled showers were not provided in each of the three months reviewed. Resident D, diagnosed with paraplegia, had a quarterly MDS and ADL care plan indicating a preference for showers or bed baths on Monday, Wednesday, and Friday evenings. Documentation revealed repeated missed showers/bed baths on multiple scheduled days in January, February, and March 2026. In an interview, Resident D reported having gone an extended period of time without receiving a shower or bed bath, although he indicated the situation had recently improved. Resident E, with acute respiratory failure with hypoxia and obesity, had an admission MDS and ADL care plan indicating a preference for showers or bed baths on Wednesdays and Saturdays between 2:00 p.m. and 10:00 p.m., but facility records showed multiple missed scheduled showers over the three-month review period. In an interview, Resident E stated that showers were frequently not given as scheduled and that she had attended physician appointments feeling unclean and uncomfortable, apologizing for her condition at a recent outside appointment. Resident F, with hemiplegia and hemiparesis following cerebral infarction, had a quarterly MDS and ADL care plan indicating a preference for showers on Tuesday and Friday evenings, yet documentation showed numerous missed scheduled showers in January, February, and March 2026. Interviews with the Administrator, a QMA, and the DON confirmed that showers were not always given as scheduled, that staffing issues due to employee absences contributed to the problem, and that showers were to be documented in the electronic record, with shower sheets corroborating the missed care. The facility’s policy on physician services and orders required all physician orders to be followed as prescribed or reasons for noncompliance to be recorded in the medical record during that shift, which was not reflected in the documentation for these missed baths and showers.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected are not included in the report. No additional information about the residents involved, their medical history, or their condition at the time of the deficiency is provided.
Failure to Provide Current Vaccine Education and Obtain Consents
Penalty
Summary
The facility failed to provide current education on influenza vaccines and to obtain current influenza vaccination consents for four out of six residents reviewed for immunizations. In several cases, the education provided regarding the risks and benefits of the influenza vaccine was outdated, with documentation dating back to 2021, and not updated for the most recent vaccination season. Additionally, some residents' records either lacked a signed and dated consent form for the influenza vaccine or had consents that were not current for the 2024-2025 season. For one resident, the administration record for the influenza vaccine was incomplete, missing the dose and location of administration, and there was also missing documentation regarding the administration or refusal of the COVID-19 vaccine. Interviews with facility staff confirmed that residents and their families had not been educated using the most current information from the CDC, and that consents for the 2024-2025 influenza season had not been provided as required. The facility's policies require that current CDC vaccine information statements be given and that signed consents be obtained prior to vaccine administration, but these procedures were not consistently followed. The deficiencies were identified through record reviews and staff interviews, which revealed gaps in both education and documentation for immunizations.
Failure in Narcotic Reconciliation Across Multiple Medication Carts
Penalty
Summary
The facility failed to ensure shift-to-shift narcotic reconciliation was completed for all six medication carts reviewed, which included the Rehab cart, Intermediate back cart, and carts for the 200, 300, 400, and 500 halls. During observations and record reviews, it was found that the Controlled Substances Check Form records lacked shift-to-shift reconciliation on multiple dates throughout June 2024. This deficiency was noted across various shifts, including day, evening, and night shifts, indicating a systemic issue in the facility's medication management practices. Interviews with the Family Tree Unit Manager and the Director of Nursing (DON) revealed that the expectation was for nursing staff to sign the Controlled Substances Check Form at the start and end of each shift. However, this task was not being completed as expected, posing a risk for drug diversion. The facility's policy on narcotic nurse-to-nurse reconciliation required two signatures for each reconciliation, but this was not adhered to, as evidenced by the incomplete counts and lack of signatures on the narcotic count sheets.
Failure to Implement Effective QAPI Measures for Narcotic Reconciliation
Penalty
Summary
The facility failed to develop and implement effective approaches to correct identified deficient practices as part of their Quality Assurance and Performance Improvement (QAPI) program. Specifically, the deficiency involved the failure of nurses to sign in and out to acknowledge reconciliation of narcotic medication at the change of shift. The Director of Nursing (DON) initiated a Performance Improvement Plan (PIP) to address this issue, with a start date of June 13, 2024, and a completion date set for September 13, 2024. The plan included reviewing sign-in/sign-out sheets, conducting a staff in-service, and initiating 'Clean Fridays' audits. However, during an interview on July 2, 2024, the DON admitted to not having any audit tools, additional documentation, or evidence to support the implementation of the approaches listed in the PIP guidance tool. Although the Family Tree Unit Manager was conducting reviews of the medication cart narcotics binders on Fridays, the DON had not yet created the 'Clean Fridays' tool. This lack of documentation and evidence of implementation led to the deficiency, as the facility did not demonstrate the development, implementation, and evaluation of corrective actions or performance improvement activities as required by their QAPI policy.
Failure to Address Resident Dietary Grievances
Penalty
Summary
The facility failed to address and resolve resident grievances in a timely manner, affecting three residents who voiced concerns about their dietary needs and preferences. Resident 30, who required dialysis three times a week, reported not receiving breakfast before his early morning appointments. Despite raising the issue with the dietary manager and the administrator, no resolution was provided, leading to the resident attending dialysis without breakfast. The dietary staff confirmed the resident's complaints but did not take action to ensure breakfast was provided, and the dietary manager was unaware of the issue, indicating a lack of communication and grievance documentation. Resident 33 experienced repeated instances of receiving food items listed on her dislikes, such as carrots, rice, and oatmeal. Despite reporting these issues to various staff members, including nurses and CNAs, the facility did not address her concerns or document them in the grievance log. The absence of a care plan for her dietary preferences and dislikes further highlights the facility's failure to acknowledge and act on her grievances, resulting in continued dissatisfaction with her meals. Resident 81 also reported receiving dietary dislikes and inadequate portion sizes, which were not addressed by the facility. Despite informing multiple staff members, including the SSD, her concerns were not documented in the grievance log, and no corrective action was taken. The facility's grievance policy outlines the process for addressing resident concerns, but the lack of adherence to this policy resulted in unresolved grievances and unmet dietary needs for the residents involved.
Failure to Report Alleged Abuse of a Resident
Penalty
Summary
The facility failed to report an allegation of resident abuse to the Indiana State Department of Health (IDOH) for one resident, identified as Resident C, who was severely cognitively impaired with diagnoses including anxiety, depression, and dementia. On a specific date, a CNA reported to the Administrator that an RN had been rough with Resident C during care, including yelling, grabbing the resident's arm, pulling her by the back of her pants, and causing her to fall hard onto the bed, which made the resident cry. The CNA considered these actions as abuse and provided a written statement to the Administrator. However, the Administrator did not report the incident to IDOH, believing it was not abuse and considering it a matter of verbiage. The facility's policy required immediate reporting of abuse allegations to IDOH, but the Administrator did not comply with this policy. Interviews with the CNA and the RN involved revealed discrepancies in the accounts of the incident, with the CNA insisting she had witnessed abuse and the RN recalling being informed of an allegation but not remembering specifics. The Administrator maintained that he did not receive a written statement from the CNA and did not perceive the actions as abusive, leading to the failure to report the incident as required by the facility's policy.
Failure to Implement Safety Plan for Resident with Wandering Behavior
Penalty
Summary
The facility failed to develop and implement a safety plan to prevent resident-to-resident abuse for a resident with dementia and a history of intrusive wandering. This deficiency resulted in the resident being hit in the face and choked by another resident. The incidents occurred when the resident, who had a known behavior of wandering into others' rooms, entered another resident's room and was attacked. Despite the facility's awareness of the resident's behavior, appropriate monitoring measures were not effectively implemented. The resident involved, identified as Resident E, had a history of dementia, anxiety, depression, and Alzheimer's disease, and was known to wander daily. The facility had previously identified the resident's behavior of rummaging through other residents' belongings and had care plan approaches to redirect the resident when exhibiting such behaviors. However, the facility's failure to implement 15-minute monitoring checks, as indicated in their preventative measures, contributed to the resident being involved in two altercations within a 24-hour period. Interviews with staff revealed that the 15-minute checks were not conducted, and the Director of Nursing confirmed that the resident was not placed on such monitoring following the initial altercation. The clinical record lacked documentation of the 15-minute checks, and the facility's policy on behavior crisis and abuse reporting was not effectively followed to ensure the resident's safety.
Failure to Timely Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure the timely completion of Quarterly Minimum Data Set (MDS) assessments for four residents, as required every three months. Resident 22's assessments were completed 4 days late in November 2023 and 3 days late in May 2024. Resident 35's assessment was completed 11 days late in June 2024. Resident 60's assessments were completed 5 days late in December 2023 and 1 day late in March 2024. Resident 73's assessment was completed 13 days late in June 2024. These delays were identified through a review of clinical records and interviews. The MDS Coordinator acknowledged the late completion of assessments, indicating that the team utilized the Resident Assessment Instrument (RAI) manual for managing MDS tasks. The work was divided between the MDS Coordinator and a co-worker. According to the RAI manual, the Quarterly MDS completion date must be no later than 14 days after the assessment reference date (ARD). The facility's failure to adhere to this timeline resulted in the identified deficiencies.
Late Submission of MDS Assessment
Penalty
Summary
The facility failed to ensure the timely submission of Minimum Data Set (MDS) assessments for a resident, leading to a deficiency. The resident, who had a clinical diagnosis of sepsis, congestive heart failure, and diabetes mellitus, was discharged from the facility. The Discharge MDS assessment for this resident had an Assessment Reference Date (ARD) of the discharge date and was completed on time. However, the assessment was transmitted electronically for submission 68 days late. The MDS Coordinator indicated that the task of assessment transmission was shared with an offsite corporate consultant, and the discharge assessment was missed in error during the transmission process. The error was discovered later, and the assessment was transmitted immediately upon discovery. The RAI manual specifies that the Discharge assessment transmission date should be no later than 14 days after the MDS completion date.
Failure to Conduct Timely Care Plan Meetings for Residents
Penalty
Summary
The facility failed to schedule, hold, and invite resident representatives to care plan meetings in conjunction with the assessment process for three residents residing on a secured dementia unit. These residents, identified as E, F, and 92, had not had care plan meetings since January 2024 or earlier, despite having multiple Minimum Data Set (MDS) assessments completed throughout the year. The facility's policy requires care plan meetings to be held within seven days of the completion of an MDS assessment, but this was not adhered to. Resident F had an annual MDS assessment completed in May 2024 and quarterly assessments in March and December 2023, with the last care plan meeting documented in June 2023. Resident 92 had quarterly MDS assessments in May and February 2024, with the last care plan meeting in January 2024. Resident E had quarterly MDS assessments in May and February 2024, with the last care plan meeting in January 2024. The Dementia Unit Manager acknowledged difficulties in scheduling these meetings due to the new frequency of MDS assessments, and no care plan meetings had been held for these residents since January 2024.
Failure to Complete Physician-Ordered Wound Care
Penalty
Summary
The facility failed to complete physician-ordered wound care treatments for a resident with an abrasion on the left foot, as observed during a survey. The resident, who was cognitively intact and used a wheelchair for mobility, had a physician's order to clean the wound with Dakins, apply collagen, and secure it with a bordered dressing every night shift on specific days. However, the treatment administration record for June 2024 showed that the wound treatments were not completed on several dates and shifts, with no documentation explaining the omissions. Interviews with facility staff, including an LPN and the DON, confirmed that the wound treatments should have been completed as ordered, and the lack of documentation left no way to verify if the treatments were administered. The facility's policy requires that all physician orders be followed as prescribed, and any deviations should be recorded in the resident's medical record. The resident's care plan indicated a risk for impaired skin integrity, and wound assessments showed changes in the wound's size and drainage over time.
Failure to Provide Ordered Wound Care for Pressure Injury
Penalty
Summary
The facility failed to provide wound care treatment as ordered for a resident with a pressure injury, leading to a deficiency in care. The resident, who had diagnoses including atrial fibrillation, weakness, and chronic pain, had a physician's order for wound care that was not consistently followed. The treatment administration record showed that wound treatments were missed on several dates and shifts, with no documentation explaining the omissions. The resident's care plan included interventions for an unstageable pressure injury on the right buttock, which was not present on admission and had evolved from a stage 2 wound. Despite the care plan and physician orders, the facility did not complete the necessary wound care treatments, as evidenced by the lack of documentation and observations of unchanged dressings. Interviews with facility staff, including an LPN and the DON, confirmed that the ordered treatments were not completed as required, which was deemed unacceptable. The facility's policy on pressure ulcer care emphasized the need for resident-centered care and adherence to professional standards to promote healing and prevent new ulcers. However, the facility's failure to consistently administer the prescribed wound care treatments resulted in a deficiency, as the resident's wound care needs were not met according to the physician's orders and the facility's policy.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to physician orders regarding oxygen administration for two residents, leading to a deficiency in respiratory care. Resident 60, diagnosed with chronic obstructive pulmonary disease (COPD), acute bronchitis, unspecified asthma, and chronic pain, was observed multiple times with her oxygen concentrator set above the prescribed 2-3 liters per minute. Despite the physician's orders and the respiratory care plan indicating the need for continuous oxygen at the specified rate, the concentrator was set at 4 liters per minute on several occasions and at 3.5 liters per minute on another occasion. The Family Tree Unit Manager confirmed the discrepancy, noting that the nurse on shift was responsible for ensuring the correct oxygen setting. Similarly, Resident 73, with diagnoses including COPD, emphysema, and unspecified atrial fibrillation, was observed with his oxygen concentrator set above the prescribed 2 liters per minute. The resident himself indicated that his oxygen should be set at 2 liters, yet observations showed it set at 3 liters and later at 3.5 liters per minute. The facility's policy mandates that all physician orders be followed as prescribed, and any deviations should be recorded in the resident's medical record. Interviews with staff, including an LPN and the Director of Nursing, highlighted the expectation that nursing staff ensure compliance with physician orders, which was not met in these instances.
Improper Labeling and Disposal of Insulin Vials
Penalty
Summary
The facility failed to ensure proper labeling and disposal of insulin vials, which are critical for managing diabetes mellitus in residents. During an observation of the 400 hall medication cart, it was found that there were open vials of Lispro and Glargine insulin that were not disposed of despite being expired. The LPN present during the observation believed insulin was good for 30 days, but the facility's documentation indicated a 28-day expiration period. This discrepancy led to the continued use of expired insulin for three residents on the 400 hall. Similarly, during an observation of the Rehab hall medication cart, two opened and undated vials of Lispro insulin and one opened undated vial of Lantus insulin were found. The LPN on duty was unaware of when these vials were opened and had not administered insulin during her shift. The facility's policy required that insulin vials be dated when opened, but this was not adhered to, resulting in a lack of proper tracking and potential use of expired medication for two residents on the Rehab hall.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to infection prevention and control procedures during wound care for two residents under Enhanced Barrier Precautions (EBPs). For Resident 70, both an LPN and a CNA entered the room, which had a visible EBP sign, and performed wound care without wearing gowns, despite the requirement for gown and glove use during high-contact care activities. The LPN and CNA leaned against the resident's mattress with unprotected clothing, and the resident's clinical record confirmed the need for EBPs, including gown and glove use for wound care. Similarly, for Resident 83, the LPN conducted wound care without donning a gown, even though the EBP sign was visible and indicated the necessity of gown and glove use for high-contact care. The LPN acknowledged the oversight and was uncertain if the EBP sign applied to the residents or their roommates. Interviews with staff, including the DON, confirmed that EBPs should have been followed, and the facility's policy outlined the requirement for gown and glove use during high-contact activities like wound care.
Failure to Timely Report Allegation of Misappropriation
Penalty
Summary
The facility failed to report an allegation of misappropriation of property within the required timeframe to the Indiana Department of Health for a resident. The resident, who was cognitively intact and had a history of a displaced intertrochanteric fracture of the left femur, alcohol abuse, difficulty in walking, and weakness, was transferred to the hospital for lethargy. Upon transfer, the resident's phone and glasses were not documented as sent with him. The resident's representative discovered the phone was missing and later tracked it to a CNA's residence, leading to a police investigation. The facility did not report the alleged misappropriation until 18 days after the initial allegation was made by the resident's representative. The resident's representative visited the facility every other day and confirmed the resident had his phone and glasses before being transferred to the hospital. When the representative visited the facility to collect the resident's belongings, the phone was missing. The facility's Administrator initially claimed the phone was sent with the resident, but the representative later received inappropriate messages from the missing phone, indicating it was stolen. Despite being informed of the theft on 3/6/24, the facility did not report the incident to the Indiana Department of Health until 3/22/24, after the police were involved and the phone was tracked to the CNA's residence. The facility's policy requires that all alleged violations involving misappropriation of resident property be reported immediately, but not later than 24 hours after the allegation is made. The Administrator acknowledged that the facility should have reported the allegation on 3/6/24 when they became aware of the theft. The delay in reporting the incident violated the facility's policy and state regulations, resulting in a deficiency citation.
Failure to Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of resident property for Resident C. Resident C, who was cognitively intact and required moderate assistance for transfers, toileting, and dressing, was transferred to the hospital for lethargy. Upon transfer, the resident's phone was reported lost, and the facility's investigation into the missing phone was delayed and incomplete. The investigation began on 3/22/24, despite the phone being reported lost on 3/4/24, and lacked detailed communication between the Administrator and the resident's representative. Additionally, the investigation did not include interviews with other staff members who were on duty at the time of the incident, and the facility did not have surveillance footage available for review. The resident's representative reported the phone missing to the police on 3/22/24 after receiving inappropriate messages from the resident's phone. The police tracked the phone to the residence of CNA 3, who was on duty during the resident's transfer. Despite this, the facility had not provided any updates on the investigation to the resident or their representative between 3/6/24 and 3/22/24. The facility's investigation included interviews with the resident's representative, the police officer, and the alleged perpetrator, but lacked interviews with other staff members and residents who might have had relevant information. Confidential interviews with several employees revealed that they were not asked any questions regarding the missing items or suspicions of misappropriation until the survey. The facility's policy on abuse prevention and reporting requires thorough investigations, including interviews with all involved parties and staff members. However, the facility's investigation into the misappropriation of Resident C's phone did not meet these standards, resulting in a deficiency in the facility's handling of the incident.
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.
