Brickyard Healthcare - Brandywine Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenfield, Indiana.
- Location
- 745 N Swope St, Greenfield, Indiana 46140
- CMS Provider Number
- 155120
- Inspections on file
- 42
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Brickyard Healthcare - Brandywine Care Center during CMS and state inspections, most recent first.
Several residents with dementia and behavioral health diagnoses exhibited frequent aggression, wandering, and self-harm ideation, but the facility did not consistently update care plans, document behavioral incidents, or review interventions with the IDT. Staff often attempted redirection, but effectiveness was not recorded, and supervision was inadequate due to staffing shortages, resulting in increased behavioral incidents and resident-to-resident altercations.
A resident with severe cognitive impairment and a history of aggression physically abused another resident with similar cognitive impairment by slapping and attempting to choke her, resulting in visible redness. The aggressive resident had prior documented behavioral issues and a care plan with interventions, but was still able to harm another resident before staff intervened.
A resident with COPD and other chronic conditions received routine nebulizer and PRN inhaler treatments, but staff failed to assess and document vital signs and lung sounds after scheduled breathing treatments as required by physician orders and facility policy. The DON confirmed that respiratory assessments should have been completed after each treatment, but the MAR lacked this documentation.
A resident with severe dementia and on hospice care did not receive scheduled Norco for several days due to unavailability, and staff failed to consistently notify the physician, hospice provider, or the resident's representative about the ongoing medication issue, as required by facility policy.
A resident with severe dementia and a history of pain requiring scheduled opioid medication did not receive their prescribed pain medication for several days, and staff failed to consistently document the resident's pain status during this period. Although the resident received two as-needed doses of morphine with documented effectiveness, there was no ongoing pain assessment recorded as required by facility policy.
A resident with severe dementia and on hospice care did not receive scheduled pain medication for five days due to unavailability, with documentation showing repeated missed doses and lack of timely communication with the provider or responsible party. Facility leadership was unaware of the issue, and required procedures for handling unavailable medications and medication errors were not followed.
The facility failed to conduct quarterly care plan meetings for several residents, including one with severe cognitive impairment and others who were cognitively intact. Despite the facility's policy supporting resident participation in care planning, meetings were not held as required, leading to a deficiency. The Social Service Director confirmed the lapse in meetings and acknowledged the responsibility of social services in organizing these meetings.
The facility failed to provide timely assistance with eating, personal care, and ambulation for residents. A resident with cognitive impairment took food from others due to delayed meal service. Another resident was not assisted with shaving or changing clothes, and missed scheduled showers. A third resident reported infrequent showers, and a resident requiring ambulation supervision was left unattended. Staff were unaware of residents' care needs, leading to inadequate assistance.
The facility failed to promote dignity for two residents. A resident with dementia was left in a chair for an extended period without being changed, resulting in him being soaked with urine. Another resident with diabetes reported that her call light was not answered promptly, leading to episodes of incontinence and humiliation. The DON acknowledged the expectation for all residents to be treated with dignity and respect.
A resident with a history of respiratory failure and diabetes experienced severe scrotal swelling and pain. Despite being cognitively intact and repeatedly requesting to be sent to the hospital, the nursing staff did not facilitate his transfer, opting instead to administer pain medication. The resident eventually called emergency services himself to be transferred to the hospital, where he was treated for scrotal swelling, urinary retention, and hematuria.
The facility failed to address grievances and care needs for two residents. A resident with diabetes and COPD filed grievances that were not properly logged or resolved, while another resident with dementia was left in a chair for extended periods without proper care. The facility did not follow its policy to forward grievances to the grievance official.
A facility failed to accurately input medication data into the MDS assessment for a resident with diabetes and dementia. The resident was incorrectly documented as being on an anti-coagulant and an antibiotic, while the EHR indicated they were on Plavix, an anti-platelet drug. The MDS Coordinator acknowledged the error, having marked the wrong tab and mistakenly believed the resident was on an antibiotic.
The facility failed to establish care plans for three residents, leading to deficiencies in addressing their specific needs. A resident with diabetes and COPD refused showers without a care plan for refusals. Another resident expressed discomfort due to a roommate's behavior, but no psychological care plan was in place. A third resident required assistance for ambulation, yet staff were unclear on his needs, and no care plan was established. The facility's policy emphasizes person-centered care plans, which were not followed.
The facility failed to maintain a wound dressing for a resident with skin cancer and did not conduct weekly skin assessments for another resident at risk for pressure ulcers. Observations showed no treatment on the resident's wound, and the last skin assessment for the other resident was conducted nearly a month prior, contrary to facility policy.
A resident at high risk for pressure ulcers did not receive weekly skin assessments as required, resulting in the development of a stage 3 pressure injury. Despite having a care plan for ulcer prevention, the facility failed to adhere to its policy, and the resident's complaints of discomfort were not adequately addressed. The Director of Nursing Services confirmed the lapse in conducting assessments, which contributed to the deficiency.
A resident with hemiplegia and hemiparesis did not receive a Range of Motion (ROM) and splint program as required. Despite an Occupational Therapy plan indicating the need for ROM exercises and splint application, the resident's care plan lacked these interventions. Staff interviews revealed confusion over responsibility for ROM exercises, with CNAs and restorative aides not providing the necessary care. The resident's family was incorrectly assumed to be assisting, contrary to the resident's statements.
A resident with severe cognitive impairment and a history of falls experienced two falls, resulting in injuries and a trip to the ER. The facility failed to update the resident's care plan with new interventions, despite policy requirements for post-fall assessments and care plan reviews.
The facility failed to ensure that two residents with weight loss were encouraged to consume nutritional supplements as recommended by the RD. A resident with schizophrenia and malnutrition was not offered a magic cup supplement during meals, and another resident with severe cognitive impairment did not receive the supplement placed on her tray. The facility's policy on providing supplements was not adhered to, resulting in a deficiency.
A facility failed to date the oxygen tubing for a resident with chronic obstructive pulmonary disease and respiratory failure. Observations revealed that the tubing was not dated, despite the resident being on continuous oxygen therapy. The facility's policy requires weekly changes of oxygen tubing, but staff were unaware of the reason for the oversight.
A resident with chronic back pain did not receive effective pain management due to the facility's failure to ensure follow-up on scheduled pain medication, document the application and removal of Lidoderm patches, and follow up on a neurosurgeon appointment. The resident reported ineffective pain relief from Tylenol, and there was no evidence of non-pharmacological interventions. Additionally, there were no current physician orders for tizanidine, a muscle relaxant previously prescribed.
A facility failed to conduct 15-minute checks for a resident with behavioral issues, as required by the care plan, after an incident where the resident allegedly placed his hand down another resident's pants. Despite the care plan's directive, staff were unaware of the checks, and no documentation indicated they were performed. The resident had a history of behavioral symptoms and moderate cognitive impairment.
A resident reported feeling uncomfortable due to a roommate's inappropriate behavior, but the facility failed to follow up on the issue. The Social Services Director was aware of the situation but did not document or address it further, citing being busy with other tasks. This deficiency was noted during a complaint investigation.
A resident with atrial fibrillation was administered an anticoagulant medication for an excessive duration, despite hospital discharge orders to discontinue it due to gastrointestinal bleeding. The facility's failure to adhere to these orders resulted in the resident receiving two doses of the medication after returning from the hospital, as confirmed by the Director of Nursing Services.
The facility failed to follow up on dental recommendations for two residents. One resident had a tooth infection requiring extraction, but despite being seen by an in-house dentist, the extraction was not performed. Another resident had rampant decay and broken teeth, with a recommendation for extraction and denture fabrication, but there was no documented follow-up for an oral surgeon referral. The facility did not ensure necessary dental care was provided, as required by their policy.
Two residents in an LTC facility were not provided with the correct thickened liquids during meal service, leading to a deficiency. One resident was given honey thickened liquids instead of the prescribed nectar thickened, and another was given nectar thickened instead of honey thickened. Both residents had specific dietary needs due to significant weight loss, and the facility's policy on thickened liquids was not adhered to.
A facility failed to maintain infection control practices during medication administration for two residents. An RN did not perform hand hygiene after removing gloves post-medication administration for one resident and before donning new gloves for another. The RN handled various items with the same gloves, breaching the facility's hand hygiene policy.
The facility failed to administer the 2024-2025 COVID-19 vaccination to two residents who had consented to receive it. Despite having consent forms signed and a list of residents needing vaccinations, the facility did not obtain physician orders or complete the vaccinations. The Director of Nursing Services acknowledged the oversight, noting a focus on influenza vaccinations first.
A resident with dementia and diabetes was physically restrained by staff during a blood sugar check, despite her refusal. RN 2, a new nurse, reported the refusal to QMA 3, who, with CNA 4, restrained the resident to complete the procedure. The incident violated the facility's restraint-free policy.
A resident with a history of aggressive behaviors and severe cognitive impairment was involved in multiple incidents of physical abuse against other residents, despite having a behavior care plan in place. The facility's interventions, such as 15-minute checks and care plan reviews, were insufficient to prevent these incidents, leading to physical harm and psychological distress for the affected residents.
A resident with borderline personality disorder sustained cuts from a hazardous door in the facility. Despite temporary fixes like duct tape, the door's sharp edges continued to cause injuries. The maintenance staff was aware of the issue, but the Executive Director was not informed of the resident's injuries. The facility's policy on maintaining a safe environment was not followed, as the door posed a safety risk.
A facility failed to conduct thorough investigations into resident-to-resident altercations involving a resident with a history of aggressive behavior. Despite having a behavior care plan, the resident was involved in multiple incidents, but the facility's documentation lacked comprehensive interviews and identification of potentially vulnerable residents, contrary to its abuse prevention policy.
A resident with multiple venous wounds on the left leg did not receive timely dressing changes as ordered by the physician. Despite specific wound care orders, the resident's medication administration record lacked daily treatments for one wound. On observation, the resident was found without dressings and reported waiting since early morning for treatment. The QMA noted the responsible nurse was overwhelmed, and the DNS was informed but occupied with another urgent matter.
The facility failed to promptly notify family members after two residents experienced falls with injuries. One resident, admitted for a short-term respite stay, had an unwitnessed fall, and the family was not informed until they visited later. Another resident, living in the dementia care unit, fell and fractured her wrist, but the correct family representative was not notified promptly, leaving the resident alone in the emergency room for hours. The facility's policy requires prompt notification, which was not followed in these cases.
Failure to Develop and Document Individualized Care Plans for Residents with Dementia-Related Behaviors
Penalty
Summary
The facility failed to provide timely and individualized care planning and documentation for residents diagnosed with dementia who displayed behavioral symptoms. Multiple residents with severe cognitive impairment and behavioral health diagnoses, such as dementia, anxiety, and PTSD, exhibited frequent behaviors including aggression, wandering, self-harm ideation, and verbal outbursts. The facility did not consistently develop or update care plans to address new or escalating behaviors, such as self-injurious actions or aggression toward others, nor did it incorporate non-pharmacological interventions recommended by psychiatric providers into the residents' care plans. Additionally, there was a lack of documentation regarding the effectiveness of interventions used to manage these behaviors, and behavioral incidents were not always reviewed by the interdisciplinary team (IDT). Observations and interviews revealed that staff often attempted redirection and reassurance, but these interventions were not always effective or documented in the clinical record. Behavioral incidents, such as physical altercations between residents, self-harm statements, and aggressive actions toward staff, were not consistently recorded in behavior monitoring tools or the medication administration record (MAR). In several cases, staff and family members reported that residents displayed behaviors almost daily, yet the clinical documentation did not reflect the frequency or nature of these incidents. Furthermore, the facility did not always provide adequate supervision, as evidenced by residents wandering into other rooms, attempting to leave the facility, or being left unsupervised in common areas. Staffing concerns were also noted, with multiple staff members and a visitor reporting that the dementia care unit was often understaffed, making it difficult to provide sufficient supervision and timely interventions for residents with behavioral health needs. The lack of adequate staffing contributed to an environment where resident-to-resident altercations and behavioral escalations occurred without prompt or effective intervention. The facility's own policy required person-centered, interdisciplinary care planning and accurate documentation of behavioral health needs, but these standards were not met for several residents during the survey period.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with severe cognitive impairment and diagnoses including dementia and diabetes was physically abused by another resident, who also had severe cognitive impairment and a history of physical aggression. The incident occurred when the aggressive resident approached the first resident in the hallway, began a verbal argument, and then slapped her on the right cheek. There was also an attempt to choke the resident, resulting in redness to her right cheek and neck. The event was witnessed by a CNA, who heard the slap and observed the altercation before staff intervened to separate the residents. Prior to this incident, the aggressive resident had a documented history of behavioral issues, including throwing water on another resident and being difficult to redirect. Her care plan identified risks for physical aggression and outlined interventions such as removing others from the area and maintaining a safe distance. Despite these interventions, the resident was able to approach and physically harm another resident, indicating a failure to protect residents from abuse as required by facility policy.
Failure to Assess and Document Respiratory Status After Nebulizer Treatments
Penalty
Summary
The facility failed to properly assess and document a resident's vital signs and lung sounds after administering routine nebulizer breathing treatments. The resident in question had multiple diagnoses, including hypertension, atherosclerotic heart disease, COPD, and a history of stroke. The care plan for this resident included interventions such as administering bronchodilators as ordered, monitoring effectiveness, and keeping the head of the bed elevated. Despite these interventions, the Medication Administration Record (MAR) for October did not include documentation of respiratory assessments or vital signs after the administration of the prescribed nebulizer treatments. Physician orders specified that the resident was to receive both scheduled nebulizer treatments and as-needed (PRN) inhaler treatments for symptoms such as wheezing and shortness of breath. While the effectiveness of a PRN inhaler dose was documented, there was no evidence that respiratory assessments or vital signs were recorded after routine nebulizer treatments. Interviews with the Director of Nursing (DON) confirmed that staff were expected to conduct respiratory assessments after all nebulizer treatments, but this was not consistently done. The resident's representative also noted that the breathing treatments and inhaler were no longer effective for the resident. Further review of facility policy revealed that staff were required to obtain vital signs and perform respiratory assessments before and after nebulizer treatments, and to document these findings in the medical record. The lack of documentation and assessment following the administration of respiratory treatments constituted a failure to follow both physician orders and facility policy, as well as accepted standards of practice for monitoring residents receiving respiratory care.
Failure to Notify Physician and Representative of Unavailable Pain Medication
Penalty
Summary
The facility failed to timely notify the attending physician, hospice provider, and the resident's representative regarding the unavailability of a prescribed pain medication for a resident with severe dementia, late-onset Alzheimer's disease, and polyosteoarthritis, who was also receiving hospice services. The resident did not receive the physician-ordered Norco (hydrocodone/acetaminophen) for pain management from the morning dose on May 21 through the evening dose on May 26, as documented in the Medication Administration Record and narcotic log. Nursing notes during this period repeatedly indicated the medication was not available, was on order, or had been reordered, but there was no documentation of consistent or ongoing notification to the physician, hospice, or the resident's responsible party about the continued lack of medication. Observation and record review confirmed that the resident was nonverbal and unable to communicate needs, further emphasizing the importance of timely notification and intervention. Facility policy required immediate action and notification to the physician and family when medications were unavailable, but documentation showed only a single instance of attempted communication with hospice and no evidence that the resident's representative was informed. The lack of documentation and follow-through on required notifications contributed to the deficiency cited during the complaint investigation.
Failure to Document Pain Status During Missed Scheduled Pain Medication
Penalty
Summary
The facility failed to consistently document the pain status of a resident who was prescribed routine opioid pain medication for pain and discomfort related to a left ankle fracture. The resident, who had severe dementia and was receiving hospice services, did not receive his physician-ordered Norco for a period of five days, as indicated by the Medication Administration Record (MAR). During this time, the MAR entry for pain assessment was blocked out, preventing staff from entering pain assessments as required by the medication order. The resident did receive two doses of as-needed morphine sulfate during this period, with documentation showing a pain level of 4 out of 10 and that the medication was effective. However, no other documentation regarding the resident's pain status was found in the nursing progress notes for the days when the scheduled pain medication was not administered. Interviews with facility leadership, including the Executive Director, DON, and Assistant DON, revealed that they were unaware of any issues related to missed scheduled pain medications. The facility's pain management policy requires a systemic approach to pain recognition, assessment, treatment, and monitoring, including the use of an appropriate pain assessment tool for residents with cognitive impairment. Despite this policy, the lack of consistent pain assessment documentation during the period when the resident was without scheduled pain medication constituted a failure to provide safe and appropriate pain management services.
Failure to Provide Scheduled Pain Medication and Investigate Medication Unavailability
Penalty
Summary
The facility failed to ensure that a resident with severe dementia, late-onset Alzheimer's disease, and polyosteoarthritis received physician-ordered pain medication (Norco 5-325 mg) as scheduled for five consecutive days. The resident, who was also receiving hospice services, did not receive the medication from the morning dose on 5-21 through the evening dose on 5-26, as documented in the Medication Administration Record (MAR) and narcotic record. Nursing notes during this period repeatedly indicated the medication was not available, was on order, or had been reordered, but there was no documentation of the medication being administered until after the gap. The facility's records showed that 56 tablets were received from the pharmacy on 5-26, but there was no time of receipt noted. During this period, there was no evidence that the resident's responsible party was notified about the missed doses, nor was there consistent documentation of communication with the medical provider or hospice regarding the unavailability of the medication. The only documented communication to the provider was on the first day the medication was unavailable. The facility's policies require immediate action when medications are unavailable, including notifying the physician, obtaining alternative orders, and monitoring the resident, but these steps were not documented as being followed. Interviews with facility leadership, including the Executive Director, DON, and Assistant DON, revealed they were unaware of any medication errors or issues with scheduled pain medication for residents during the relevant period. The Corporate Nurse later confirmed that staff had reached out to hospice for a new prescription, as hospice was responsible for the order, but was unable to locate documentation of this communication for the period in question. The lack of timely administration of pain medication and failure to follow policy for unavailable medications and medication errors led to the deficiency.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct quarterly care plan meetings for four out of five residents reviewed, leading to a deficiency in care planning. Resident G, who was severely cognitively impaired, had not had a care plan meeting since October of the previous year, despite the family member's role as power of attorney and their expressed concern about poor communication. Resident 39, who was cognitively intact and valued family involvement in care discussions, had not had a care plan meeting since June of the previous year. The Social Service Director confirmed the lapse in meetings and acknowledged the responsibility of social services in organizing these meetings. Resident 22, who was cognitively intact, reported that a care plan meeting was scheduled but not rescheduled after he was unable to attend due to illness. The resident had only two documented care plan meetings in the previous year and none in the current year. Resident 80, also cognitively intact, had not been invited to any care plan meetings since admission. The facility's policy supports resident participation in care planning, but the lack of adherence to this policy resulted in the deficiency. The facility's failure to hold regular care plan meetings as required by their policy and regulations was confirmed by the Social Service Director.
Deficiencies in Resident Care and Assistance
Penalty
Summary
The facility failed to provide timely assistance with eating for a resident with severe cognitive impairment, resulting in the resident taking food and drinks from other residents. During a lunch meal service, the resident was observed reaching for and consuming another resident's coffee and attempting to take food from their tray. Despite staff intervention, the resident continued to take items from other residents until they were finally provided with their meal tray. Another resident, who required assistance with personal care due to dementia, was observed wearing the same soiled shirt over multiple days and had not been shaved despite expressing a desire to do so. The resident's broken razor was not replaced, and staff did not assist with shaving as promised. The resident's shower schedule was also not adhered to, with records indicating missed showers and no documentation of refusals. A third resident, who was cognitively intact, reported not receiving showers as frequently as desired, with documentation showing missed scheduled showers and no refusals recorded. Additionally, a resident requiring supervision for ambulation was left unattended with their walker out of reach, leading them to walk unassisted. Staff were unaware of the resident's transfer and ambulation needs, resulting in inadequate supervision and assistance.
Failure to Promote Resident Dignity and Timely Care
Penalty
Summary
The facility failed to promote dignity for two residents, Resident B and Resident H, as evidenced by the findings in the report. Resident B, who has dementia and anxiety, was reported to have been left sitting in a chair for an extended period without being changed, resulting in him being soaked with urine. A grievance was filed regarding this issue, highlighting that Resident B was not assisted with toileting needs from 9:30 a.m. to 9:30 p.m. Resident F, who is cognitively intact, expressed concern about the treatment of Resident B, describing it as disrespectful and ridiculous. Resident H, who has diabetes and chronic obstructive pulmonary disease, reported that her call light was not answered promptly, leading to episodes of incontinence. She provided handwritten notes documenting several instances where her call light was on for over thirty minutes before being answered. One specific incident resulted in Resident H sitting in her waste for over an hour, causing her to feel disgusting and humiliated. The Director of Nursing Services acknowledged the expectation for all residents to be treated with dignity and respect.
Failure to Timely Transfer Resident to Hospital for Severe Pain
Penalty
Summary
The facility failed to timely follow up on a resident's request to be transferred to the hospital for treatment of scrotal swelling and pain. Resident J, who was cognitively intact and had a history of respiratory failure and diabetes, experienced severe scrotal swelling and pain. Despite his repeated requests to be sent to the emergency room, the nursing staff did not facilitate his transfer. Instead, they administered pain medication as per the on-call provider's instructions. Resident J eventually called emergency services himself to be transferred to the hospital. The nursing progress notes and interviews with staff revealed that Resident J's requests to go to the hospital were not acted upon promptly. The Assistant Director of Nursing confirmed that it was the facility's expectation to send alert and oriented residents to the hospital per their request. However, the staff failed to adhere to this expectation, resulting in Resident J's delayed transfer to the hospital. The hospital records indicated that Resident J was admitted for scrotal swelling, urinary retention, and hematuria, and he received treatment for these conditions.
Failure to Address Resident Grievances and Care Needs
Penalty
Summary
The facility failed to ensure that grievances filed by residents were properly forwarded to the grievance official and resolved. Resident H, who has diabetes and chronic obstructive pulmonary disease, reported filing two grievances, one at the end of February and another about two weeks prior to the interview. However, only one grievance was logged, and Resident H indicated that no follow-up was conducted regarding her grievances. Resident 68 corroborated that Resident H had submitted both grievances to a Qualified Medication Aide (QMA). The facility's grievance log only recorded one grievance for Resident H, and there was no evidence of resolution or follow-up. Additionally, Resident F, who has an anxiety disorder, expressed concerns about the care of his roommate, Resident B, who has dementia and anxiety. Resident F filed a grievance on behalf of Resident B, noting that staff left Resident B sitting in a chair for extended periods without changing or toileting him. The grievance resolution stated that Resident B should be placed back to bed after meals, but observations showed that Resident B was often left sleeping in a chair in the common room. The facility's policy requires staff to forward grievances to the grievance official promptly, but this procedure was not followed, leading to unresolved grievances and inadequate care for the residents involved.
Inaccurate MDS Medication Data Entry
Penalty
Summary
The facility failed to accurately input medication data into the Minimum Data Set (MDS) assessment for a resident, leading to a deficiency in MDS accuracy. The resident, who had diagnoses including diabetes mellitus and dementia, was incorrectly documented as being on an anti-coagulant and an antibiotic in the Admission MDS assessment. However, the resident's Electronic Health Record (EHR) showed no current orders for these medications. Instead, the resident was on Plavix, an anti-platelet drug, not an anti-coagulant. The MDS Coordinator admitted to marking the wrong tab for the anti-coagulant and mistakenly believed the resident was on an antibiotic during the seven-day look-back period, resulting in erroneous data entry.
Deficiencies in Care Planning for Resident Needs
Penalty
Summary
The facility failed to establish comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. Resident H, who has medical diagnoses of diabetes and chronic obstructive pulmonary disease, was found to have refused nine showers in the last 60 days. Despite this, there was no care plan in place to address her refusals of care. Resident J, diagnosed with respiratory failure and diabetes, expressed discomfort due to his roommate's behavior, yet there was no care plan to address his psychological needs. Additionally, Resident 190, who has diagnoses of pain and anxiety, required supervision or touch assistance for ambulation. However, there was a lack of clarity among staff regarding his transfer and ambulation status, as evidenced by interviews with a registered nurse and a certified nurse aide. No care plan was established to guide staff on Resident 190's transfer or ambulation needs. The facility's policy on comprehensive care plans emphasizes the importance of developing person-centered care plans for all residents' needs, which was not adhered to in these cases.
Failure in Wound Care and Skin Assessment
Penalty
Summary
The facility failed to ensure proper wound care for Resident G, who was diagnosed with dementia, anxiety disorder, insomnia, vertigo, and a neoplasm of uncertain behavior of the skin. Despite a physician's order to cleanse the right forehead with wound cleanser, pat dry, apply Vaseline, and cover with foam every other day, observations on multiple occasions revealed that no treatment was in place for the resident's right forehead. A family member, who is the power of attorney for Resident G, expressed concerns about the facility's communication and the cancer center's worries regarding the lack of healing and improper treatment of the wound. Additionally, the facility did not conduct weekly skin assessments for Resident 59, who was diagnosed with asthma, Alzheimer's disease, chronic pain, and unspecified psychosis. Although the resident was at risk for pressure ulcers, the last documented weekly skin assessment was conducted nearly a month prior to the review. This failure to adhere to the facility's policy for weekly skin assessments contributed to the deficiency identified during the survey.
Failure to Conduct Weekly Skin Assessments Leads to Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident received weekly skin assessments, which led to the development of a pressure injury. Resident 39, who had diagnoses including polyneuropathy, pain, and anxiety, was identified as being at high risk for pressure ulcers with a Braden score of 12. Despite having a care plan initiated for the prevention of pressure ulcers, the resident did not receive a skin assessment between 2/22/25 and 3/12/25. During this period, a new stage 3 pressure injury developed on the resident's right gluteus, which was acquired in-house. The facility's policy required weekly skin assessments by licensed nurses, but this was not adhered to, as confirmed by the Director of Nursing Services. The resident reported discomfort and informed aides about the issue, but it was dismissed as redness from scratching. The deficiency was further highlighted during a wound care observation where the resident expressed pain. The Director of Nursing Services acknowledged that the floor nurses and unit managers failed to maintain the required weekly assessments, contributing to the oversight and subsequent development of the pressure injury.
Failure to Implement ROM and Splint Program for Resident
Penalty
Summary
The facility failed to develop and implement a Range of Motion (ROM) and splint program for a resident with limited ROM, identified as Resident 75. The resident, who has a history of hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage, expressed that he was not receiving ROM exercises and felt stiff, requiring assistance to move his extremities. Despite an Occupational Therapy evaluation and discharge summary indicating the need for a functional maintenance program of ROM and splint/brace program, the resident's plan of care did not include these interventions. Observations confirmed the resident's right arm was flaccid, and he was not utilizing it for mobility, nor was a splint consistently applied. Interviews with facility staff, including CNAs and the Director of Therapy, revealed a lack of clarity and responsibility regarding the provision of ROM exercises. CNAs indicated that restorative aides were responsible for ROM programs, yet the restorative aide confirmed that Resident 75 was not on a restorative program for ROM exercises. The Director of Therapy mistakenly believed the resident's family was providing ROM exercises, which the resident refuted, stating his family was unable to assist due to their own health issues. The facility's policy on preventing decline in ROM was not adhered to, as the resident did not receive the necessary interventions to maintain or improve his ROM.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to adequately conduct a fall follow-up and implement necessary interventions for a resident identified as being at risk for falls. The resident, who was severely cognitively impaired and had a history of falls, experienced two falls within a short period. The first fall occurred when the resident was startled by an alarm, resulting in a trip to the emergency room for pain evaluation. The second fall was unwitnessed and occurred when the resident attempted to get out of bed, which was in a high position, leading to injuries that required sutures. Despite these incidents, the resident's care plan was not updated with new interventions to prevent future falls. The facility's policy on fall prevention required a post-fall assessment, incident report, and care plan review and update, none of which were fully completed following the falls. The interdisciplinary team assessment also failed to document additional interventions after the second fall, indicating a lack of comprehensive follow-up and preventive measures.
Failure to Encourage Nutritional Supplement Consumption
Penalty
Summary
The facility failed to ensure that residents with weight loss were encouraged to consume nutritional supplements as recommended by the Registered Dietitian (RD). Resident D, who had diagnoses including schizophrenia, diabetes mellitus, and malnutrition, was observed during meal services where staff assisted with eating but did not offer or encourage the consumption of a magic cup supplement that was part of his dietary plan. Despite the presence of the supplement on the meal tray, it remained unopened during both breakfast and lunch, indicating a lack of adherence to the care plan interventions. Similarly, Resident 46, with severe cognitive impairment and a history of significant weight loss, was not encouraged to consume a magic cup supplement during lunch. The resident's meal tray contained the supplement, but it was not opened or placed near her for consumption. The facility's policy on nutritional and dietary supplements, which mandates providing supplements consistent with assessed needs, was not followed, leading to a deficiency in the nutritional care provided to these residents.
Failure to Date Oxygen Tubing for Resident
Penalty
Summary
The facility failed to ensure that oxygen tubing was dated for a resident receiving oxygen therapy. During multiple observations, it was noted that the oxygen tubing used by a resident with chronic obstructive pulmonary disease and respiratory failure was not dated. The resident was on continuous oxygen at two liters per minute via nasal cannula, as per their care plan initiated earlier in the month. Despite the facility's policy requiring oxygen tubing to be changed weekly and as needed, the tubing for this resident was not dated, and the staff, including a registered nurse, were unaware of the reason for this oversight.
Inadequate Pain Management and Documentation for a Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident with chronic back pain, dementia, and hypertension. The resident, who was moderately cognitively impaired, received scheduled pain medication but did not receive follow-up to ensure its effectiveness. The resident reported that the Tylenol administered was not effective, and there was no documentation indicating the effectiveness of the medication. Additionally, the resident's pain was frequently rated above five on a ten-point scale, yet there was no evidence of non-pharmacological interventions being used. The facility also failed to document the application and removal of Lidoderm patches as per the physician's order. The patches were to be applied daily and removed after 12 hours, but there was no documentation in the medication administration record to confirm their removal. This lack of documentation could lead to excessive dosing and increased absorption of lidocaine, posing a risk to the resident. Furthermore, the facility did not follow up on a scheduled appointment with a neurosurgeon for the resident's chronic back pain. Despite multiple progress notes indicating the need for follow-up, there were no notes or further instructions from the neurosurgeon in the resident's clinical record. Additionally, there were no current physician orders for the use of tizanidine, a muscle relaxant, which had been previously prescribed for a limited duration. The facility's failure to ensure proper documentation and follow-up care contributed to inadequate pain management for the resident.
Failure to Conduct 15-Minute Checks for Resident with Behavioral Issues
Penalty
Summary
The facility failed to ensure that 15-minute checks were initiated for a resident with behavioral issues, leading to a deficiency in behavioral health care and services. Resident E, who had a history of behavioral symptoms directed towards other residents, was involved in an incident where he allegedly placed his hand down another resident's pants. Despite the care plan indicating that 15-minute checks were to be initiated following this incident, interviews and record reviews revealed that these checks were not conducted. The facility's staff, including a Qualified Medication Aide, were unaware of the requirement for 15-minute checks, and no documentation was found to indicate that these checks were ever performed. Resident E had diagnoses including diffuse traumatic brain injury and alcohol dependence, and a Quarterly Minimum Data Set assessment indicated moderate cognitive impairment. The incident report and staff interviews highlighted that Resident E exhibited fatherly behavior towards other residents, attempting to care for them, which required staff intervention and redirection. Despite the initiation of behavioral monitoring every shift starting the day after the incident, the lack of adherence to the care plan's 15-minute checks represented a failure in providing necessary behavioral health care and services.
Failure to Address Resident's Psychosocial Needs
Penalty
Summary
The facility failed to adequately address the psychosocial needs of Resident J, who was cognitively intact and had a history of depression and a psychotic disorder. Resident J reported feeling uncomfortable and disgusted due to his roommate, Resident E, engaging in inappropriate behavior with the door and curtain open. Despite Resident J's report to the staff about a month to six weeks prior, the Social Services Director (SSD) only instructed Resident E to pull the curtain but did not follow up on the issue or document it in the clinical record. The SSD acknowledged being aware of the situation from an intradisciplinary team meeting but admitted to not following up due to being occupied with other tasks. The facility's policies on documentation and social services emphasize the importance of addressing residents' grievances and ensuring their dignity, which was not adhered to in this case. This deficiency was identified during a complaint investigation related to Resident J's concerns.
Failure to Discontinue Anticoagulant Medication
Penalty
Summary
The facility failed to administer an anticoagulant medication as ordered by the physician, resulting in the medication being given for an excessive duration to a resident with atrial fibrillation. The resident, identified as Resident 88, was at risk for complications related to anticoagulant medication. Despite a hospital discharge order to discontinue the anticoagulant apixaban (Eliquis) due to gastrointestinal bleeding and low hemoglobin levels, the medication was administered twice after the resident returned to the facility. The resident's clinical record indicated a change in condition with symptoms of bloody stools and abdominal pain, leading to a hospital transfer where the anticoagulant was discontinued. However, upon returning to the facility, the medication administration record showed that the resident received two doses of apixaban, contrary to the hospital's discharge instructions. The Director of Nursing Services confirmed that the medication should not have been administered, highlighting a failure in medication management and adherence to the facility's policy on unnecessary drugs.
Failure to Follow Up on Dental Recommendations for Two Residents
Penalty
Summary
The facility failed to follow up on dental recommendations for two residents, Resident G and Resident 12, who were reviewed for dental services. Resident G had a history of a tooth infection dating back to December 2024, for which a physician ordered a dental appointment for possible extraction. Despite being seen by an in-house dentist on two occasions, there was no indication that the necessary tooth extraction was performed. The resident's care plan indicated a need for dental services, but the facility did not ensure the extraction was completed, and communication with the resident's family was inadequate. Resident 12 also experienced a lack of follow-up on dental care. The resident had a history of rampant decay and broken teeth, with a recommendation for extraction and denture fabrication made in May 2024. Despite a referral for an oral surgeon due to possible abscess and the need for sedation for x-rays, there was no documented follow-up in the resident's clinical record. The facility's policy required assistance with dental appointments and documentation of any delays, but these actions were not adequately performed for Resident 12.
Failure to Provide Appropriate Thickened Liquids
Penalty
Summary
The facility failed to provide appropriate thickened liquids to two residents during meal service, leading to a deficiency in maintaining resident hydration. During an observation in the Alzheimer's Care Unit, a CNA assisted a resident with consuming an orange drink that was not consistent with the resident's prescribed nectar thickened liquid diet. The resident's care plan and physician order specified a puree diet with nectar thickened liquids, but the CNA mistakenly used a drink from another resident's tray, which was honey thickened. This oversight occurred despite the resident's history of significant weight loss and the need for specific dietary interventions. In a separate observation, another resident was given a yellow thickened liquid labeled as nectar thick, contrary to the resident's prescribed honey thickened liquid diet. The CNA involved was unaware of the correct fluid consistency for the resident and only realized the mistake after reviewing the meal ticket. The resident's care plan and physician order indicated a need for honey thickened liquids due to a history of significant weight loss. The facility's policy on thickened liquids, which requires adherence to physician or dietitian orders based on individual assessments, was not followed in these instances.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during a medication administration observation involving two residents. During the observation, a Registered Nurse (RN) prepared and administered medications to Resident 246 and Resident 247 without adhering to hand hygiene protocols. Specifically, the RN donned gloves to prepare and administer medications to Resident 246 but did not perform hand hygiene after removing the gloves. Subsequently, the RN proceeded to prepare medications for Resident 247 without conducting hand hygiene before donning a new pair of gloves. The RN continued to handle various items, including an insulin pen, medication cart keys, and a laptop, while wearing the same gloves used during the administration of insulin to Resident 247. It was only after completing the medication administration for Resident 247 that the RN removed the gloves and performed hand hygiene. The facility's hand hygiene policy, dated May 2024, clearly states that hand hygiene should be performed prior to donning gloves and immediately after removing them, indicating a breach in protocol by the RN.
Failure to Administer COVID-19 Vaccination to Consenting Residents
Penalty
Summary
The facility failed to obtain a physician's order and administer the 2024-2025 COVID-19 vaccination to two residents who had consented to receive it. Resident 23, with a medical history including chronic obstructive pulmonary disease, diabetes mellitus, heart disease, end-stage renal disease, and hypertension, consented to the vaccination on October 16, 2024. However, his electronic health record indicated that his most recent COVID-19 vaccination was administered on January 26, 2023. Similarly, Resident 50, diagnosed with Alzheimer's disease and anxiety, consented to the vaccination on December 6, 2024, but his record showed the last vaccination was on March 14, 2024. The Director of Nursing Services acknowledged the issue, stating that the facility prioritized influenza vaccinations and was still working on COVID-19 vaccinations. Despite having a list of residents needing vaccinations, the facility had not yet obtained the necessary orders or completed the vaccinations. The facility's policy required offering COVID-19 vaccinations to residents when supplies were available, following CDC and FDA guidelines, and maintaining documentation of consent and administration. However, the facility did not adhere to these guidelines for the two residents in question.
Resident Restrained During Blood Sugar Check
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraint during a blood sugar check. Resident B, who had diagnoses including dementia, mood disorder, and diabetes, was involved in the incident. The resident resided in the memory care unit and had a care plan that emphasized explaining procedures and providing reassurance. Despite this, during a blood sugar check, the resident was physically restrained by staff members. The incident occurred when RN 2, a new nurse in training, attempted to check Resident B's blood sugar. The resident refused the procedure, prompting RN 2 to report the refusal to QMA 3, who was her preceptor. QMA 3 then took over and, with the assistance of CNA 4, physically restrained Resident B to obtain the blood sugar reading. RN 2, although present, did not participate in the restraint but was instructed to perform the blood sugar check while the resident was held down. Interviews with the involved staff revealed discrepancies in their accounts of the event. RN 2 and CNA 4 admitted to the use of physical restraint, while QMA 3 denied any involvement in restraining the resident. The Executive Director conducted an investigation after being informed of the incident by corporate, confirming that physical restraint was used without the resident's consent, which violated the facility's policy on maintaining a restraint-free environment.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent three incidents of resident-to-resident physical abuse involving Resident B, who has a history of aggressive behaviors and severe cognitive impairment. Resident B, diagnosed with bipolar disorder, intellectual disabilities, encephalopathy, and anxiety disorder, exhibited physical and verbal abusive behaviors. Despite having a behavior care plan in place, Resident B was involved in multiple incidents of physical abuse against other residents, including Resident D, Resident G, and Resident E. The facility's interventions, such as 15-minute checks and care plan reviews, were not sufficient to prevent these incidents. Resident D, who has post-traumatic stress disorder, major depressive disorder, and anxiety disorder, was physically assaulted by Resident B when attempting to leave an office. Resident D reported being hit on the head and shoulder, resulting in a red mark. Resident G, diagnosed with mood disorder and schizophrenia, was also assaulted by Resident B while trying to get coffee. Resident G was punched in the stomach and arm, leading to soreness and a sense of insecurity within the facility. Resident E, with major depressive disorder, dementia, and mood disturbances, experienced multiple assaults by Resident B, including being hit on the head, which caused damage to Resident E's glasses. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the repeated incidents involving Resident B. Despite the known history of aggressive behaviors and the refusal of psychiatric services by Resident B's next of kin, the facility did not adequately address the risk of resident-to-resident abuse. The lack of effective interventions and monitoring allowed Resident B to continue exhibiting aggressive behaviors, resulting in physical harm and psychological distress to other residents.
Failure to Maintain Safe Environment Due to Hazardous Door
Penalty
Summary
The facility failed to maintain a safe environment for Resident G, who was affected by an environmental hazard involving an outside door. Resident G, diagnosed with borderline personality disorder, reported that the back door leading to the parking lot had sharp edges that caused him to sustain cuts on his forearm. Despite temporary fixes by the maintenance staff, such as applying duct tape over the broken areas, the issue persisted, and Resident G continued to experience injuries. The resident used the door frequently to go outside, and the nursing staff was aware of his injuries as they provided band-aids for the cuts. During an observation with the Executive Director and Maintenance Supervisor, it was noted that the door had a metal edge protector that was initially installed in late 2023 but had since deteriorated, leading to the use of duct tape as a temporary solution. The duct tape wore out quickly, exposing the sharp edges again. The Executive Director was unaware of the resident's injuries and had only recently begun seeking quotes for a permanent repair. The facility's policy on providing a safe and homelike environment was not adhered to, as the physical layout posed a safety risk to the resident.
Inadequate Investigation of Resident Altercations
Penalty
Summary
The facility failed to maintain documentation of a complete and thorough investigation into alleged violations, specifically regarding resident-to-resident physical altercations involving Resident B. Resident B, who has medical diagnoses including bipolar disorder, intellectual disabilities, encephalopathy, and anxiety disorder, was involved in three documented physical altercations with other residents. Despite having a behavior care plan in place, Resident B exhibited aggressive behaviors on multiple occasions. The facility's incident reports for these events lacked comprehensive documentation, including interviews with additional residents and staff, and did not identify potentially vulnerable residents. The facility's policy on abuse, neglect, and exploitation requires the implementation of procedures to prevent and prohibit abuse, including the identification and assessment of residents with behaviors that might lead to conflict. However, the investigations into the incidents involving Resident B did not adhere to these policies. The Executive Director acknowledged that additional resident and staff interviews were not conducted, and potentially vulnerable residents were not identified. The interventions following the incidents were limited to increased monitoring, such as 15-minute checks, without a thorough investigation or identification of residents at risk.
Failure to Timely Complete Dressing Changes for Resident's Wounds
Penalty
Summary
The facility failed to complete timely dressing changes for a resident with multiple venous wounds on the left leg, as ordered by the physician. Resident D, who was cognitively intact and had a history of lymphedema, peripheral vascular disease, hypertension, and type 2 diabetes mellitus, was readmitted to the facility from the hospital. Upon readmission, the resident had cellulitis on the left leg, and specific wound care orders were provided, including cleansing and dressing changes every other day and as needed. However, the resident's medication administration record did not include daily treatments for one of the venous wounds, as recommended by the nurse practitioner. On the day of the observation, Resident D was found without dressings on his lower left leg and reported waiting since early morning for his treatments. The Qualified Medication Aide indicated that the nurse responsible was overwhelmed, and the Director of Nursing Services was informed but was addressing another urgent matter. The facility's policy required wound care to be provided in a manner that decreases the potential for infection, specifying the type of dressing and frequency of changes, which was not adhered to in this case.
Failure to Promptly Notify Family After Resident Falls
Penalty
Summary
The facility failed to promptly notify the resident's representative following a fall with injury for two residents. Resident E, who was admitted for a short-term respite stay in the secured dementia care unit, experienced an unwitnessed fall resulting in a bump on her forehead. Despite the fall occurring around noon, the family was not notified until they visited the facility later that evening. The Director of Nursing (DON) acknowledged the delay in notification, admitting responsibility for not contacting the family sooner. Resident G, who had been living in the secured dementia care unit for over two years, fell and sustained a fractured left wrist. The fall occurred in the morning, and the resident was sent to a local emergency room for evaluation and treatment. However, the facility failed to notify the correct family representative promptly. The daughter, who was the healthcare representative, was not informed of the incident until much later, resulting in the resident being alone in the emergency room for nearly 10 hours. The facility's policy on Notification of Changes requires prompt notification of the resident's representative in the event of an accident or injury. However, in both cases, the facility did not adhere to this policy, leading to delayed communication with the residents' families. The DON later identified issues with the contact list ordering, which contributed to the notification errors.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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