Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookside Care Strategies during CMS and state inspections, most recent first.
A CNA refused to answer a resident’s call light, told him not to use it, and failed to provide timely hygiene and ostomy care, leaving him in urine-soaked bedding and tearful and afraid. Staff statements described the CNA as dismissive of the resident’s repeated needs and reported that another aide had to step in to provide care. The resident had multiple mental health and cognitive diagnoses, along with an ileostomy and vision impairment, and the facility’s policy identified withholding care as neglect and threatening to withhold care as verbal abuse.
Failure to Immediately Report Alleged Abuse and Neglect: A resident reported that a CNA yelled at him, complained about his call light use, and left him in urine-soaked bedding without care until the next shift. Staff statements described the CNA refusing call lights and providing delayed or improper care, but the allegation was not immediately escalated to the Administrator and was not reported to IDOH within the required timeframe. The resident had diagnoses including mild ID, PTSD, anxiety, depression, and an ileostomy.
A facility failed to immediately investigate an allegation that a CNA yelled at a resident, threatened to withhold care, and left him in a urine-soaked bed until the next shift. Staff statements described the resident as crying, scared, and upset, with concerns about improper ostomy care and missed call lights. Leadership was not promptly notified of the abuse/neglect allegation, and the CNA continued working after the report was made.
The facility failed to ensure that two residents and/or their representatives received or signed transfer/discharge notices and bed hold documents when they were sent to outside psychiatric hospitals. One resident with alcohol dependence, anxiety, and TBI had multiple hospital transfers with missing signed notices, and one transfer lacked both the notice and bed hold policy. Another resident with dementia, insomnia, and HTN was sent to an inpatient psychiatric hospital, but the transfer/discharge notice and bed hold policy were not signed by the resident or representative. Staff stated these documents were given to EMTs, but could not confirm they were provided to the resident or representative.
An LPN failed to follow contact isolation precautions while administering insulin to a resident with a MRSA wound infection, entering the room without a gown despite signage requiring gown and gloves. In a separate event, an LPN handled medications with bare hands and without hand hygiene before administering them to a resident with multiple psychiatric and neurologic diagnoses. The facility also failed to follow EBP during catheter care when a CNA emptied a resident’s urinary catheter bag while wearing gloves only, despite signage requiring gown and gloves for device care.
Survey Results Not Readily Accessible: Residents stated they did not know where the Indiana Dept. of Health Annual Survey Report was located, and two residents wanted to review it but could not find it. A posted sign near the entrance said the results were available at the nurse's desk, but the binder was actually kept behind the nurse's station under the nurse's desk, where residents, representatives, and guests could not access it without asking staff. The Administrator also noted the sign was posted high enough that it could be difficult for individuals in wheelchairs to read.
Daily staff posting was not readily accessible or visible to residents and visitors. On 5 of 5 days reviewed, the staffing information was framed on a wall behind the nurse's station and could not be read without entering the nurse's station. QMA 15, an LPN, QMA 12, and the Administrator each stated they could not read the posting from in front of the nurse's station, and the Administrator acknowledged residents and visitors were not allowed behind the desk to view it.
A resident with severe cognitive impairment and dementia was at the nurse’s station holding a QMA’s hand when a CNA approached and made a derogatory remark implying the QMA should bleach or disinfect her hands after contact with the resident. The comment was made within the resident’s hearing and in the resident’s presence, and the QMA perceived it as disrespectful and undignified. In interviews, the CNA acknowledged making the statement while the resident was nearby, though she claimed she did not intend for the resident to hear it or view it as demeaning. Facility leadership, including the DON and Administrator, identified the remark as disrespectful, undignified, and a form of verbal abuse that violated the resident’s right to dignity and respectful treatment.
The facility failed to report an allegation of abuse to the state agency after a resident told a CNA during personal care that a housekeeper had kissed her on the lips multiple times and had been communicating with her via social media for about a week. The CNA documented the disclosure and notified facility management, and a subsequent statement indicated the resident said the kiss was wanted and that she did not want the housekeeper to get into trouble. The housekeeper denied kissing the resident but admitted to social media messaging, and the resident later recanted her original statement, saying she made it up to get closer to him. The Administrator, aware of these details and of the facility’s abuse policy requiring reporting of alleged violations to the Department of Health when required by law or regulation, chose not to report the allegation to the state agency.
A resident with multiple chronic conditions was subjected to verbal abuse by an Activity Assistant during a smoke break, where both parties exchanged insults and the staff member made inappropriate remarks about the resident's health. Staff witnesses confirmed the incident, and the facility's abuse prevention policy was not followed despite regular staff education.
A cognitively impaired resident who required substantial assistance and frequent redirection was subjected to verbal abuse by a maintenance staff member. The staff member made threatening and intimidating statements, including threats of physical harm, in response to the resident's behaviors. Multiple staff witnessed the incident, and the facility's investigation confirmed that the staff member's actions constituted verbal and mental abuse.
The facility failed to maintain 24-hour licensed nurse coverage on multiple days, with PBJ and clock-in/clock-out records showing gaps in RN/LPN coverage across January, February, and March 2025. The facility assessment showed significant resident acuity, including behavioral/mental health needs for 39 residents, medication administration for 39 residents, respiratory treatments for 3 residents, hospice care for 1 resident, and wound care for 2 residents. The Administrator, QMA responsible for scheduling, and DON each described staffing issues and efforts to fill shifts, while the DON said she could not verify the uncovered shifts from the reports available to her.
RN Staffing Shortfall: The facility failed to ensure RN coverage for 8 hours in a 24-hour period on multiple days, with PBJ staffing records showing no RN coverage on numerous days across the quarter. The Administrator, DON, and QMA stated they were aware of the staffing issues and described using clock-in/clock-out reports and attempts to fill shifts through messaging and sister facilities, while the facility policy required 24-hour nursing services and 8 consecutive hours of RN coverage daily.
The facility did not provide quarterly funds statements to two residents whose personal funds were managed by the facility, as required by policy. Staff acknowledged that statements were not given to residents without a responsible party, resulting in the deficiency.
The facility did not maintain a surety bond sufficient to cover all resident funds it managed, as required by policy. On multiple occasions, the balance of resident funds exceeded the bond amount, and the Business Office Manager confirmed that no reviews were conducted to ensure adequate coverage.
A resident with multiple medical conditions experienced a significant change in condition, including symptoms such as tachycardia, hypertension, and refusal of medication and fluids. Staff failed to notify the resident's representative of these changes as required, only informing them after the resident was ordered to be transferred to the ER. Facility policy and staff interviews confirmed that notification should have occurred at the time of the initial change.
The facility did not provide necessary social services to two residents requiring assistance with financial management. One resident's cash was stored in the Social Service office without documentation or a care plan, and the family was not informed. Another resident, with significant cognitive impairment, had funds exceeding Medicaid limits, but there was no evidence of assistance or care planning to help spend down resources, and the resident was unaware of the available funds.
A resident with acute and chronic respiratory failure was receiving continuous oxygen, but the record lacked a current physician order for oxygen administration and flow rate. The resident reported using oxygen via NC all the time except when smoking, while the concentrator was observed set at 4 lpm; APRN notes documented different oxygen settings, and the DON acknowledged the resident did not have a current oxygen order even though one should have been in place.
Incomplete daily nurse staffing information was posted and not kept current for residents and visitors. The staffing sheet behind the nurse's station showed outdated and inaccurate RN, LPN, and CNA coverage, including shifts listed with no staff when clock-in/clock-out records showed staff were actually present. QMA 9 said she updated the posting each morning from the schedule, and the Administrator confirmed she was responsible for the daily posting.
QAPI Failure to Address Repeat Nurse Staffing Posting Deficiency: The facility was cited again for failing to ensure daily nurse staffing information was complete, accurate, and readily available to residents and resident representatives. Surveyors found the same issue had been cited in the prior annual survey, and the Administrator stated the matter was not reviewed in QAPI after the prior plan of correction was completed. The deficiency had the potential to affect 39 of 39 residents.
Failure to document and offer flu and pneumococcal vaccinations: The facility lacked vaccine education, administration, or verification records for three residents reviewed. One cognitively intact resident had no influenza or pneumococcal vaccine documentation, another had an unspecified prior pneumococcal vaccine that could not be verified and no proof of an offer for additional vaccination, and a third resident signed consent for Pneumovax 23 but the record did not show it was given. The DON could not locate the missing vaccination information.
The facility failed to educate and offer the COVID-19 vaccine to an employee reviewed for compliance. An CNA stated she had worked at the facility for about two years and had not been educated on or offered the COVID-19 vaccination, and the IP stated there was no documentation of vaccination education or offerings from 2024. The facility policy called for encouraging staff, residents, and visitors to stay up to date with COVID-19 vaccines and providing resources and counseling about vaccination.
A facility failed to sanitize a multi-use blood glucose monitoring device per manufacturer's guidelines. A QMA used an alcohol swab to clean the device between testing two residents, which was insufficient according to the manufacturer's policy. The DON confirmed the inadequacy of the sanitization method used.
The facility failed to administer insulin as prescribed for three residents, resulting in missed doses and inadequate documentation. A resident with type 2 diabetes did not receive Lantus and Lispro as ordered, while another with type 1 diabetes missed Novolog doses. A third resident with diabetes and hypoglycemia also had missed Humalog doses. The DON noted staff were not signing off on the eMAR, leading to documentation gaps.
A facility failed to suspend an employee accused of abuse, as required by its policy, when a resident alleged that the employee kicked his foot intentionally. Despite the resident's request for further action and his wish to avoid interaction with the employee, the accused was not suspended during the investigation. The facility's policy mandates suspension of the accused until a full investigation is completed, but this was not followed, leading to a deficiency.
The facility failed to maintain safe food temperatures in its refrigerators, impacting all residents. A refrigerator was found at 48°F, with logs showing missing entries and no guidance on acceptable ranges. Despite being informed, the Dietary Manager did not verify temperatures, relying on staff reports. The facility policy required storage below 41°F, which was not followed.
The facility failed to implement an effective QAPI program, resulting in repeat deficiencies related to improperly labeled medications and incomplete narcotic reconciliation sheets. The Administrator admitted to not having a recent QAPI plan and lacked record-keeping of meeting minutes. An audit tool for pharmacy services was insufficiently detailed, and the QAPI plan provided was outdated, contributing to the facility's inability to address and prevent repeat deficiencies.
The facility failed to maintain a functional call light system, impacting all 34 residents. Instead, residents were given manual bells, which were often out of reach and inadequate, especially for those with physical limitations. The call light system had been inoperable for months, and management was aware but had not yet arranged for its repair or replacement. Residents had to resort to yelling or using personal phones to summon help, and staff found it challenging to identify which resident needed assistance.
The facility did not ensure that the most recent survey results were accessible to residents and their representatives. The survey binder, located behind the nurse's station, only contained surveys dated before 11/27/23, despite complaint surveys being conducted after this date. The Administrator was unaware that complaint surveys needed to be included, contrary to facility policy.
The facility failed to follow its grievance policy, as the Social Services Director resolved complaints immediately without documentation, contrary to the policy requiring written responses and reports. The last recorded grievance was several months ago, indicating a lack of adherence to the established grievance process.
The facility did not effectively implement an infection control program, as evidenced by the lack of prior tracking and trending of resident infections. The Infection Preventionist, new to the position and splitting time between locations, was unaware of previous infection control measures and only recently completed the Infection Log using antibiotic orders. The facility's policy required an infection control program, but it was not effectively executed.
The facility failed to provide chairs in resident rooms, affecting all 34 residents. Residents expressed a need for chairs during confidential interviews, with some having to sit on beds or tables. Observations confirmed the absence of chairs in multiple rooms. The Administrator was unaware of the requirement, citing space issues, and the DON confirmed no policy on room furniture.
A facility failed to create a baseline care plan for a resident at risk for pressure ulcers upon admission. The resident, with a history of chronic kidney disease and other conditions, did not receive a Braden Scale risk assessment, which is essential for pressure ulcer prevention. The DON confirmed the absence of a baseline care plan, violating the facility's policy.
A resident at risk for pressure ulcers was not assessed upon admission, leading to the development of heel wounds. Despite physician orders for interventions, the facility failed to consistently implement and document preventative measures, such as pressure relief boots and repositioning schedules. Observations showed the resident often in bed with heels against the mattress, and staff interviews revealed a lack of awareness of the resident's care needs.
A resident with severe cognitive impairment and multiple mental health diagnoses exhibited disruptive behaviors in a common area. Despite having a care plan with specific interventions, staff failed to implement these measures, resulting in a deficiency. The resident's actions included pounding on walls and throwing furniture, causing fear among peers. Staff did not attempt to de-escalate the situation or document interventions, and security cameras were not functioning properly during the incident.
The facility failed to ensure proper shift-to-shift narcotic count and reconciliation for two medication carts. Observations revealed missing narcotic card counts and reconciliation signatures for numerous dates in August and September 2024. Interviews with QMAs indicated that the narcotic count was supposed to be completed during shift changes, but this was not consistently done. The DON confirmed that the expectation was for staff to complete the narcotic count sheet at the start and end of each shift, as per facility policy.
The facility failed to properly label and store medications, as observed in two medication carts. A Levemir insulin vial was not discarded after 30 days, and lidocaine patches lacked resident identifiers. A Humalog insulin Kwikpen was found without an open date. Facility policies require proper labeling and storage, which was not followed.
A resident reported an allegation of inappropriate touching by another resident, which the facility investigated and deemed unsubstantiated. However, the facility failed to report the incident to the Indiana Department of Health as required by their policy and state guidelines, leading to a deficiency finding.
A facility failed to thoroughly investigate an alleged sexual abuse incident involving a resident who reported inappropriate touching by another resident. The investigation lacked essential details, such as specific times and comprehensive interviews with staff and other residents. Despite the facility's policy requiring a detailed investigation, the process was halted due to insufficient evidence from limited surveillance footage.
The facility did not post nurse staffing information in a clear and accessible format for three consecutive days. Observations showed no staffing numbers were posted, and interviews with the DON and Administrator revealed reliance on a schedule book kept at the nurse station, which did not meet the policy requirement for prominent posting.
A facility failed to honor a resident's right to return after an ER visit following an altercation. Despite no significant behavioral changes noted at the hospital, the facility discharged the resident to a distant homeless shelter without proper notice or appeal opportunity. The resident was later found by police and hospitalized for dehydration and acute kidney injury.
A resident with a history of cognitive and behavioral issues was improperly discharged from a facility after a hospital visit. The facility failed to provide a 30-day notice or allow an appeal, instead leaving the resident at a hotel without proper documentation. This led to the resident's hospitalization for dehydration and acute kidney injury.
A cognitively impaired resident was physically abused by another resident with a history of aggression. Despite care plans and interventions, the aggressive resident's behaviors persisted, leading to an incident where the impaired resident was found with a head laceration after entering the aggressive resident's room. The facility's failure to adequately supervise and protect the wandering resident resulted in this altercation.
The facility failed to ensure proper labeling of medications for a resident, as observed during a medication administration. Two bottles of oral Nystatin lacked resident identifiers and instructions, and the RN was unable to identify the prescribed resident. The DON also did not know how the medication was received without appropriate labels, violating the facility's policy on medication labeling.
Resident Left in Soiled Bedding After CNA Refused Care and Used Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse and neglect when a CNA refused to answer the resident’s call light, refused to provide personal hygiene assistance, and told the resident not to use the call light. The resident reported that the CNA yelled at him, left him in a urine-soaked bed overnight, and that he did not receive care until the next shift. The resident was upset, tearful, and afraid of the CNA. His clinical record showed diagnoses including mild intellectual disabilities, PTSD, anxiety disorder, major depressive disorder, blindness of the right eye, low vision of the left eye, and ileostomy. The resident’s grievance and multiple staff statements described that the CNA was upset about the resident’s call light use and his colostomy/ileostomy care. One staff member stated the CNA said the resident always had his call light on and refused to answer it, while another stated the CNA told the resident she did not have time to keep coming to his room and told him not to use the call light for the rest of the night. Staff also reported that the resident’s bedding was wet with urine, his colostomy bag had been left improperly closed, and another aide had to provide care because the resident was distressed and crying. One staff member stated the resident was scared and did not want the CNA in his room. The resident’s grievance was written by another CNA and placed in leadership mailboxes, but leadership initially did not know about the concern. The DON stated she was not aware of the resident’s concern or a filed grievance until later. The facility policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and identified threatening to withhold care as verbal abuse. The report also states the facility had not sent the CNA home pending investigation during the survey dates.
Failure to Immediately Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to report an allegation of verbal abuse and neglect immediately to the Administrator and failed to ensure the allegation was reported to the Indiana Department of Health within two hours. Resident 10 stated that CNA 9 yelled at him, told him he was on his call light too much, and left him in a urine-soaked bed overnight without care until the next shift. Resident 10 was upset during the interview and said this was not the first time this had happened. He also reported that he had filed a grievance and wanted assurance the behavior would not happen again. Multiple staff interviews and written statements showed that concerns about CNA 9’s care were discussed among staff, but the report of neglect and possible abuse was not immediately escalated to leadership. CNA 11 completed the grievance form for Resident 10 and placed it in the Social Service Designee’s and Administrator’s mailboxes, but did not call leadership to report abuse or neglect. The Administrator stated he had no knowledge of the concern until later, and the DON indicated she was not aware that the concern involved withholding care or neglect when it was first discussed. Staff statements described CNA 9 refusing to answer call lights, complaining about Resident 10’s call light use, and leaving the resident in wet bedding while other staff had to provide care. Resident 10’s record showed diagnoses including mild intellectual disabilities, PTSD, blindness in one eye, low vision in the other eye, anxiety disorder, major depressive disorder, and ileostomy. His care plan included assistance with toileting and incontinence care, and his MDS indicated mild cognitive impairment but that he usually understood others. The facility policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and identified threatening to withhold care as mental and verbal abuse. The Indiana Department of Health policy required alleged abuse or neglect to be reported immediately, but no later than two hours after the allegation was made.
Failure to Immediately Investigate Alleged Verbal Abuse and Neglect
Penalty
Summary
The facility failed to immediately begin an investigation of an allegation of staff-to-resident verbal abuse and neglect involving a resident who reported that a CNA yelled at him, told him he was on his call light too much, and left him in a urine-soaked bed overnight until the next shift provided care. The resident stated he was very upset, had filed a grievance, and wanted assurance the behavior would not happen again. The resident’s clinical record showed diagnoses including mild intellectual disabilities, PTSD, anxiety disorder, major depressive disorder, blindness of the right eye, low vision of the left eye, and an ileostomy. His care plan included assistance with toileting/incontinent care and monitoring for skin issues, as well as care plans for anxiety and depression. The grievance and multiple staff statements showed that on the day of the event, staff observed the CNA refusing to answer call lights, complaining about the resident’s call light use, and failing to provide timely care. One staff member stated the resident’s colostomy/ileostomy bag was not properly closed, another staff member had to provide care because the resident’s bed was wet, and the resident was crying and distressed. Another statement indicated the CNA told the resident she did not have time to keep coming to his room and should not use the call light for the rest of the night. Staff also reported that the resident was scared, upset, and did not want the CNA in his room. The facility did not treat the allegation as an abuse/neglect report when it was first raised. The grievance form and staff statements were placed in leadership mailboxes, but leadership was not immediately notified of a report of neglect and/or abuse. The Administrator stated he had no knowledge of the concern when the grievance was first discussed, and the DON stated she did not recognize the earlier written statement as related to the allegation until later. The CNA involved continued to work scheduled shifts after the allegation was made and was not sent home pending investigation until later. The facility policy required alleged abuse or neglect to be reported immediately, no later than two hours after the allegation, with immediate action to protect the resident and preventative measures while the investigation was in progress.
Failure to Provide Transfer/Discharge and Bed Hold Notices
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed of transfer/discharge notices and bed hold documents for 2 of 4 residents reviewed for hospitalization. Resident 42 had diagnoses of alcohol dependence, anxiety, and traumatic brain injury. The record showed multiple transfers to a neuropsychiatric hospital, including on 10/7/25 at 4:50 p.m., 2/5/26 at 3:01 a.m., and 3/5/26 at 8:12 p.m. For these events, the record lacked signed notices of transfer/discharge by the resident or representative, and for the 3/5/26 transfer the record also lacked a notice of transfer/discharge and bed hold policy. Resident 26 had diagnoses of dementia, insomnia, and hypertension. The record showed the resident was sent to an inpatient psychiatric hospital on 2/23/26 at 3:46 a.m., but the notice of transfer/discharge and bed hold policy was not signed by the resident or representative. During interviews, QMA 15 and LPN 16 stated that when residents were sent to the hospital, a medication list and bed hold policy were given to EMTs, but they could not recall whether the documents needed to be given to the resident or representative. The Social Services Director stated nursing staff were supposed to send residents with a medication list, notice of transfer/discharge, and bed hold policy, and that family and resident representatives were notified of the transfer.
Infection Control Failures During Isolation, Medication Administration, and Catheter Care
Penalty
Summary
The facility failed to use infection prevention and control measures during insulin administration for a resident who was on contact isolation for a MRSA wound infection. During observation, an LPN entered the resident’s room wearing only gloves, obtained a blood glucose reading, removed the gloves, and then returned to the room to administer insulin without a gown. The LPN leaned against the resident’s bed sheets with her pant leg while providing care. The resident’s room had a contact isolation sign stating that a gown and gloves were required before entry, and the resident’s record showed a right foot diabetic ulcer with a wound VAC and current contact barrier precautions for wound drainage. The facility also failed to follow infection control practices during medication administration for another resident. During observation, an LPN opened the medication cart drawers, popped medications into a cup without performing hand hygiene, and then handled medications with bare hands. The LPN removed a quetiapine tablet from the cup with her fingers, placed it into pudding, crushed buspirone and ropinirole into the pudding, and used bare hands to open quetiapine capsules and pour the contents into the pudding before administering them. The resident’s record showed diagnoses including Parkinson’s disease, paranoid schizophrenia, generalized anxiety disorder, major depressive disorder, and mood disorder. The facility further failed to follow enhanced barrier precautions during catheter care for a resident with a urinary catheter. The resident’s door sign indicated that staff must clean their hands and wear gloves and a gown for high-contact care activities, including device care or use such as urinary catheter care. During observation, a CNA entered the room wearing gloves, opened the catheter collection bag spout, emptied urine into a graduated cylinder, and then performed hand hygiene and adjusted the resident’s blankets. The CNA and the Infection Preventionist stated that a gown was supposed to be worn during high-contact care for residents on enhanced barrier precautions.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to ensure the Indiana Department of Health Annual Survey Report was readily available for residents and visitors to review without having to request it from staff. During a Resident Group Interview, residents stated they did not know where the survey report was available and two residents said they wanted to review the annual survey report but did not know where it was located. A posted sign near the front entrance indicated the annual survey results were available at the nurse's desk, but the sign was placed over 6 feet high. During observation and interview, the Annual Survey Report binder was found behind the nurse's station, under the nurse's desk. An LPN, a QMA, and the Administrator each indicated residents, representatives, and guests were not allowed behind the nurse's desk and would have to ask a staff member to obtain the binder for them. The Administrator also stated the sign showing the binder's location was posted about 6 feet high and could be difficult for individuals in wheelchairs to read. The facility policy titled Resident Rights stated residents have the right to examine survey results.
Daily Staff Posting Not Visible or Readable
Penalty
Summary
The facility failed to ensure that daily staff posting was readily accessible and visible to residents and visitors for 5 of 5 days reviewed. During general facility observations on 5/17/26, 5/18/26, 5/19/26, 5/20/26, and 5/21/26, the daily staff posting was framed on a wall behind the nurse's station and positioned so it could not be read without entering the nurse's station. The posting was located approximately eight feet from where staff were standing in front of the nurse's station, and it was not readable from that position. During interviews on 5/20/26, QMA 15, LPN 3, and QMA 12 each indicated they were unable to read the daily staff posting from in front of the nurse's station. On 5/21/26, the Administrator also stated he was unable to read the posting from in front of the nurse's station and acknowledged that residents and visitors were not allowed to go behind the desk in the nurse's station to read it. A current facility policy titled, Posting Direct Care Daily Staff Numbers, revised August 2022, stated the staffing information must be posted in a prominent location accessible to residents and visitors and in a clear and readable format.
Derogatory Staff Comment in Resident’s Presence Violates Dignity and Abuse Protections
Penalty
Summary
The deficiency involves a failure to protect a resident’s right to be treated with respect and dignity when a staff member made a derogatory statement about the resident within the resident’s hearing. The resident involved had diagnoses including moderate dementia with mood disturbance and a cognitive communication deficit, and an admission MDS assessment indicated the resident was severely cognitively impaired. A progress note documented that a staff member made an inappropriate statement about the resident to another staff member in front of the resident, and although the resident later stated he did not hear the statement and denied psychosocial distress, the incident was recognized as a concern for the resident’s psychosocial well-being. During interviews, a QMA reported that she had been at the nurse’s station holding the resident’s hand when a CNA approached and stated that the QMA should probably bleach her hands because she was holding the resident’s hand. This comment was made in front of the resident, who was next to the QMA and talking at the time, and the QMA perceived the statement as disrespectful and undignified. The QMA noted that, although the resident was cognitively impaired and might not have processed the remark, it was made within a distance that the resident could have heard it, and that if the resident had been cognitively intact, the statement would have hurt his feelings. In a separate interview, the CNA acknowledged that she had walked up to the nurse’s station and, seeing the resident touching the QMA’s hands and arms, muttered that she would use bleach wipes afterward, referring to the resident’s contact. She admitted the resident was within hearing distance when she made the remark but stated she did not intend for the resident to hear it and did not believe her statement was humiliating or demeaning. The DON and Administrator both indicated that the remark was made in the presence of the resident, was disrespectful and undignified, and had the potential to hurt the resident’s feelings, constituting verbal abuse and a violation of the resident’s right to a dignified existence and to be treated with respect.
Failure to Report Allegation of Staff-Resident Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the state agency as required by policy and regulation. An anonymous report to the Indiana Department of Health alleged that a staff member was having an affair with a resident and that facility management failed to act on the allegation. During an interview, the Administrator stated that while a CNA was assisting a resident with a shower, the resident disclosed that she and a housekeeper had kissed. The CNA reported this allegation to management. Written statements from the CNA indicated the resident reported that when she was sad, the housekeeper asked what he could do to make her feel better, she requested a kiss, and he kissed her on the lips three times. The CNA documented that the resident asked her not to tell anyone because she did not want to get anyone in trouble. A typed statement indicated that the Infection Prevention Nurse and Business Office Manager were informed that the housekeeper had been in the resident’s room and kissed the resident, and that the resident stated the kiss was wanted and she did not want the housekeeper to get into trouble. The statement also documented that the interaction had been occurring for about a week and that the resident and housekeeper had been messaging each other through a social media platform. The Administrator reported that the housekeeper denied kissing the resident but admitted to messaging the resident on social media. The Administrator further indicated that, after the resident initially confirmed the kissing, she later recanted and said she made up the story to get closer to the housekeeper. Based on the resident’s later recantation, the Administrator decided not to report the allegation to the state agency, despite the facility’s abuse policy requiring that alleged violations of abuse be reported immediately to the Administrator or designee and, when required by law or regulation, to the Department of Health.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A resident with diagnoses including schizophrenia, chronic pneumothorax, muscle wasting and atrophy, and depressive disorder was involved in a verbal altercation with an Activity Assistant. The resident, who was noted to refuse care daily, called the Activity Assistant a derogatory name after expressing frustration about the timing of receiving a cigarette during a smoke break. In response, the Activity Assistant made disparaging remarks about the resident's health condition and returned the insult, engaging in further disrespectful comments. Multiple staff statements confirmed that the Activity Assistant responded to the resident's insult with additional derogatory remarks, referencing the resident's use of oxygen and choice to smoke. The facility's investigation included written statements from staff who witnessed the incident, all of whom confirmed the exchange of verbal insults. The facility's abuse prevention policy defines verbal abuse as inappropriate oral, written, or gestured communication directed at residents. Despite routine abuse education provided to staff, the Activity Assistant's conduct constituted verbal abuse, as it involved inappropriate and disrespectful communication towards the resident.
Staff-to-Resident Verbal Abuse of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with diagnoses including Asperger's syndrome, altered mental status, malignant neoplasm of the parotid gland, and generalized anxiety disorder was involved in a verbal altercation with a maintenance staff member. The resident was noted to be severely cognitively impaired, requiring substantial assistance with daily activities and frequent redirection due to repetitive vocalizations and behaviors. On the morning of the incident, the resident was near the medication cart, engaging in his usual repetitive verbalizations and behaviors, when a maintenance staff member approached and engaged in a verbal exchange. Multiple staff statements and interviews confirmed that the maintenance staff member responded to the resident's behaviors by making threatening and intimidating statements, including telling the resident, "If you touch me, I will put you on the ground," and provoking the resident to approach him. The staff member also made disparaging remarks about the resident in front of other staff. Witnesses described the staff member's actions as antagonizing, intimidating, and threatening, with one LPN specifically identifying the behavior as verbal and mental abuse. The resident, upon hearing the threat, quickly left the area. The facility's investigation substantiated the allegation of verbal abuse, with the maintenance staff member admitting that his statements were inappropriate and acknowledging that, according to facility education, it was abusive to humiliate, intimidate, or threaten residents. The facility's policy clearly states that all residents have the right to be free from abuse, including verbal and mental abuse by staff. The incident was reported and documented by staff, and the facility's investigation confirmed the occurrence of staff-to-resident verbal abuse.
Licensed Nurse Coverage Gaps
Penalty
Summary
The facility failed to ensure licensed nursing coverage on a 24-hour basis for 11 days during the second quarter of 2025. A PBJ Staffing report identified dates in January, February, and March 2025 when there was no continuous RN or LPN coverage. A review of the facility assessment, updated 8/1/25, showed resident acuity affecting licensed nurses included respiratory treatments for 3 residents, behavioral/mental health needs for 39 residents, medication administration for 39 residents, hospice care for 1 resident, and wound care for 2 residents. The assessment also listed overall staffing needs of 2 RNs and 4 LPNs providing direct care, with available staff documented as 4 RNs, 4 LPNs, and 3 QMAs. During interviews, the Administrator stated he was aware of licensed nurse staffing issues in January, February, and March 2025 and said clock-in/clock-out reports were reviewed and sent to corporate for reporting licensed nurse coverage hours. QMA 9, who was responsible for scheduling, stated she tried to ensure 24-hour licensed nurse coverage by making multiple attempts to fill hours through the company messaging system and by calling sister facilities for additional staff. The DON stated she was not aware of any shift without an LPN or RN on staff and said she could not verify the listed dates because she did not have access to the clock-in/clock-out reports. A record review of those reports showed multiple gaps in licensed nurse coverage on the dates identified in the PBJ report.
RN Staffing Shortfall
Penalty
Summary
The facility failed to ensure a Registered Nurse was present in the facility for 8 hours during a 24-hour period for 25 days of the 2nd Quarter of 2025 reviewed for sufficient staffing. A Payroll-Based Journal staffing report showed no RN coverage on 1/3, 1/6, 1/9, 1/10, 1/11, 1/12, 1/17, 1/20, 1/23, 1/24, 1/25, 1/26, 1/27, 1/31, 2/3, 2/6, 2/7, 2/8, 2/9, 3/8, 3/9, 3/23, 3/29, and 3/30. The deficiency had the potential to affect 39 of 39 residents residing in the facility. During interviews, the Administrator stated he was aware the facility had issues staffing RNs in January, February, and March of 2025 and that he reviewed clock-in/clock-out reports weekly before sending them to the corporate office for reporting RN hours. The DON stated she used the clock-in/clock-out process for her scheduled shifts, usually worked 9:00 a.m. to 5:00 p.m., often stayed later, and was available by telephone at all times. QMA 9 stated she was responsible for scheduling and made multiple attempts to fill RN hours through the company messaging system and by calling sister facilities to obtain additional RNs. A facility policy titled Department Duty Hours, Nursing Services stated nursing service is provided 24 hours per day, seven days a week, and that the facility requires an RN for 8 consecutive hours per day, 7 days a week.
Failure to Provide Quarterly Funds Statements to Residents
Penalty
Summary
The facility failed to provide quarterly funds statements to residents for whom it managed personal funds, specifically for two out of three residents reviewed. Record review showed that the facility managed funds for 32 residents, and quarterly statements were requested for three of these residents. However, two residents did not have quarterly statements available for review. During interviews, the Administrator and Business Office Manager acknowledged that quarterly statements had not been given to residents who did not have a responsible party, which was an error, as the residents themselves should have received the statements. Facility policy requires that residents be provided with a confidential quarterly statement of funds on deposit.
Insufficient Surety Bond Coverage for Resident Funds
Penalty
Summary
The facility failed to provide a surety bond in an amount sufficient to safeguard all resident funds managed by the facility. Record review showed that the facility managed funds for 32 residents, and the surety bond in place covered only $30,000.00. However, bank statements for May, June, and July 2025 revealed that on 23 separate days, the daily ledger balance of resident funds exceeded the bond amount, with balances reaching as high as $48,374.65. During an interview, the Business Office Manager confirmed that the facility did not conduct reviews to ensure the surety bond was adequate for the actual balance of resident funds, as this responsibility was handled by the home office. The facility's policy required it to act as a fiduciary and safeguard resident funds, but this was not met due to the insufficient bond coverage.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative regarding a significant change in condition for one resident. The resident, who had diagnoses including paranoid schizophrenia, hypertension, and gastro-esophageal reflux disease, was noted to be mildly cognitively impaired. On the day in question, the resident was found to be cool, clammy, tachycardic, and hypertensive, and refused both blood pressure medication and fluids. Nursing notes from this period did not document any notification to the resident's family or representative about these changes in condition. Later that day, the resident continued to exhibit symptoms such as excessive sweating, tachycardia, hypertension, and tachypnea, and again refused medications and fluids. The nurse practitioner was contacted and ordered the resident to be sent to the emergency room, at which point the resident's representative was informed of the transfer. Interviews with staff confirmed that the expectation was to notify the resident's representative when a change in condition was identified, and that this should be documented in the progress notes. However, the initial significant change in the resident's condition was not communicated to the representative as required by facility policy.
Failure to Provide Social Services for Resident Financial Management
Penalty
Summary
The facility failed to provide appropriate social services related to financial management for two residents who required assistance with managing their funds and maintaining Medicaid eligibility. For one resident with paranoid schizophrenia and moderate cognitive impairment, the Social Services Director stored $900 in cash in a locked file cabinet in her office without any documentation, receipts, or care plan regarding the funds. The resident's family was not informed about the storage or management of the money, and there was no method to account for expenditures. At discharge, $700 was returned to the family, who questioned the amount, and the Administrator was unaware that the funds had been kept in the Social Service office. For another resident with hypertension, diabetes, major depressive disorder, and unspecified dementia, the facility acted as representative payee and held a balance exceeding Medicaid asset limits. Although the resident received multiple written notifications about the excess funds, there was no documentation that the information was verbally shared or that assistance was offered to help spend down the resources. The resident, who was moderately cognitively impaired and required decision-making assistance, was unaware of the excess funds and expressed interest in using money for personal items. The clinical record lacked a care plan or documentation of actions taken to assist with financial management to maintain Medicaid eligibility.
Missing Physician Order for Oxygen Therapy
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when the facility failed to obtain physician orders for oxygen services for one resident who was receiving continuous oxygen. The resident was cognitively intact and had diagnoses including acute and chronic respiratory failure, atrial fibrillation, and generalized anxiety disorder. During interviews, the resident stated he used oxygen at 3 lpm via nasal cannula all the time except when smoking, and the oxygen concentrator was observed set at 4 lpm. The resident later stated the oxygen flow had not been adjusted, and the concentrator remained set at 4 lpm on subsequent observations. The resident’s record contained current orders for nebulizer tubing changes and PRN albuterol nebulization, but it lacked orders for oxygen administration and flow rate. The care plan referenced oxygen per physician orders, and APRN notes documented oxygen settings of 3 lpm and later 4.5 lpm. The DON stated the resident used continuous oxygen and was on 2 lpm per physician order, then later acknowledged the resident did not have a current oxygen order but should have had one. The facility policy titled Oxygen Administration directed staff to check the physician’s order for oxygen, liter flow, and method of administration.
Incomplete Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure that complete and accurate daily nurse staffing information was posted and readily available for residents and resident representatives. During observation, the Daily Staffing Posting without Units was seen posted behind the nurse's station, but it was dated 8/14/25 at 7:34 a.m. On 8/18/25 at 9:30 a.m., the posting showed that no RN or LPN were scheduled for the evening and night shifts and no CNA were scheduled for the night shift. On 8/20/25 at 9:32 a.m., the posting indicated there were no RNs or LPNs on the evening shift. During interview, QMA 9 stated she was responsible for updating the nurse staffing post every day, arriving between 8:30 and 9:00 a.m. to print the document from the online system. She explained that the online system pulled information from the schedule she completed, that open shifts were filled as quickly as possible, and that both the schedule and daily posting were updated when shifts were filled. She also stated that weekend postings were printed on Friday and changed by floor staff on Saturday and Sunday. Review of the facility staffing clock-in/clock-out sheets showed that on 8/18/25 there was an RN present on the evening and night shifts, an LPN present on the evening shift, and 2 CNAs present, and on 8/20/25 there was one LPN present on the evening shift. The Administrator confirmed that QMA 9 was responsible for completing the daily staff posting each morning.
QAPI Failure to Address Repeat Nurse Staffing Posting Deficiency
Penalty
Summary
The facility failed to develop and implement approaches to maintain a QAPI program to prevent repeat deficiencies related to daily nurse staffing information posting. Review of the prior annual recertification and state licensure survey completed on 9/26/24 showed the facility had already been cited for failing to ensure nurse staffing information was readily available in a readable format to residents and visitors each day. The prior plan of correction stated that a new updated form would be placed in an accessible area, staff completing the daily staffing information would be educated, and the Administrator and/or designee would ensure the current day's staffing information was completed each morning. During the August 18, 2025 survey, surveyors found that complete and accurate daily nurse staffing information was again not posted and readily available for residents and resident representatives. The deficiency had the potential to affect 39 of 39 residents. During interview on 8/22/25, the Administrator stated the prior plan of correction was completed on 1/17/25, that audit tools showed no concerns and staffing was posted appropriately, and that the issue was not reviewed in QAPI after that date. A facility policy titled Quality Assurance & Performance Improvement (QAPI) Program Process, dated 4/19, stated the program was intended to identify areas in need of improvement, implement action for resolution of known problem areas, and provide audit tools for immediate corrective action.
Failure to Document and Offer Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide education for and offer influenza and/or pneumococcal vaccinations to 3 of 5 residents reviewed for immunizations. Resident 7 had diagnoses including heart failure, asthma, and anxiety disorder, and an 8/7/25 quarterly MDS indicated the resident was cognitively intact. The clinical record lacked influenza and pneumococcal vaccine education or administration documentation, and the DON stated she was unable to locate information regarding the resident’s influenza or pneumococcal vaccination status. Resident 5 had diagnoses including acute and chronic respiratory failure, hypertension, and anxiety disorder, and a 7/17/25 quarterly MDS indicated the resident was cognitively intact. The record showed an unspecified pneumococcal vaccine in 2013 before admission, but the facility could not verify what type of vaccine was received and could not verify the resident was offered additional pneumococcal vaccination on admission. Resident K had diagnoses including coronary artery disease, malignant neoplasm of the prostate, hypertension, and hyperlipidemia, and a 4/15/25 annual MDS indicated severe cognitive impairment. The resident signed consent for Pneumovax 23 on 12/12/24, but the record lacked documentation that the vaccination was provided, and the DON stated she was unable to locate documentation showing the vaccine was administered.
Failure to Educate and Offer COVID-19 Vaccine to Staff
Penalty
Summary
The facility failed to educate and offer the COVID-19 vaccine to employees, as shown by the review of CNA 8. During an interview on 8/22/25 at 8:45 a.m., CNA 8 stated she had worked at the facility for about two years and had not been educated on or offered the COVID-19 vaccination during that time. During an interview with the IP on 8/22/25 at 8:57 a.m., the IP stated the facility had no documentation of vaccination education or offerings from 2024. A current facility COVID-19 Vaccination Policy provided by the DON on 8/22/25 at 11:05 a.m. stated that infection prevention and control measures include encouraging staff, residents, and visitors to remain up-to-date with COVID-19 vaccine doses and providing resources and counseling about the importance of receiving the COVID-19 vaccine.
Improper Sanitization of Blood Glucose Monitoring Device
Penalty
Summary
The facility failed to properly sanitize a multi-use blood glucose monitoring device according to the manufacturer's guidelines during a random observation of blood glucose testing. On the specified date, a Qualified Medication Aide (QMA) was observed using an alcohol swab to clean the device between testing two residents, which was not in compliance with the manufacturer's instructions. The QMA used the same device for multiple residents, wiping it with an alcohol swab after each use, and then returned it to the medication cart. During interviews, the QMA confirmed that an alcohol swab was used for sanitizing the device between residents, and it was the only device available on the medication cart. The Director of Nursing (DON) acknowledged that using an alcohol wipe was insufficient for sanitizing the multi-use glucose monitoring device. The manufacturer's policy, provided by the Scheduler, specified that only certain EPA-registered wipes should be used, and the device surfaces must remain wet for the contact time specified by the wipe manufacturer to prevent the transmission of bloodborne pathogens.
Failure in Insulin Administration and Documentation
Penalty
Summary
The facility failed to ensure proper insulin administration for three residents, leading to multiple missed doses and lack of documentation. Resident B, diagnosed with type 2 diabetes mellitus, had several instances where insulin was not administered as per physician's orders. Specifically, Lantus was not given in the morning as prescribed, and Lispro was not administered before meals on certain dates. Additionally, there was a failure to document blood sugar readings and missed doses in the progress notes. Resident C, with type one diabetes mellitus, also experienced missed doses of Novolog, both as a regular dose and per sliding scale, on consecutive days. Similarly, Resident D, diagnosed with type two diabetes mellitus and hypoglycemia, had missed doses of Humalog on specified dates. The Director of Nursing acknowledged that staff were not signing off on medication administration, resulting in blank spaces on the electronic medication administration record (eMAR).
Failure to Suspend Employee Accused of Abuse
Penalty
Summary
The facility failed to implement its abuse prohibition policy effectively when an employee accused of abuse was allowed to remain in the facility during the investigation. Resident B, who was cognitively intact, alleged that a Care Specialist (CS 1) kicked his foot intentionally. Despite the resident's request for the Administrator to contact the State Agency, police, and ombudsman, and his wish for CS 1 to avoid any interaction with him, the employee was not suspended during the investigation. Instead, CS 1 was merely instructed to stay away from Resident B. The facility's current policy, dated December 1, 2021, clearly states that if an employee is suspected of abuse, they should be suspended until the incident is fully investigated. However, the Administrator did not follow this procedure, as he believed the incident had already been resolved. This failure to adhere to the policy resulted in a deficiency, as the accused employee was not suspended, potentially compromising the safety and well-being of Resident B.
Refrigerator Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to ensure that refrigerators were functioning at a level to maintain safe food temperatures, potentially impacting all 34 residents. During an initial kitchen tour, a standard white refrigerator was found to be at 48 degrees Fahrenheit, containing pre-poured drinks and sliced cheeses. The dietary staff member acknowledged that the refrigerator should be between 36 to 38 degrees Fahrenheit and suspected the door had been left open too long. However, the refrigerator temperature logs for September 2024 showed that temperatures had not been recorded for several days, with the white refrigerator and freezer missing entries since 9/18/24, and the silver units since 9/19/24. The logs also lacked guidance on acceptable temperature ranges. Further observations during lunch meal preparation revealed the white refrigerator at 50 degrees Fahrenheit, with orange juice inside registering at 57.6 degrees Fahrenheit. Despite being informed of the issue, the Dietary Manager had not checked the refrigerator temperature since the initial concern was raised, relying instead on staff reports that temperatures were 40 degrees Fahrenheit or less. The facility's policy stated that refrigerated foods must be stored below 41 degrees Fahrenheit, which was not adhered to, as evidenced by the consistent temperature issues and lack of proper monitoring.
Facility Lacks Effective QAPI Program Leading to Repeat Deficiencies
Penalty
Summary
The facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) program effectively, leading to repeat deficiencies. During the last annual recertification and licensure survey, deficiencies were identified related to improperly labeled medications and incomplete shift-to-shift narcotic reconciliation sheets. Despite the plan of correction indicating that ongoing corrective action would be monitored through the facility's QAPI program, the facility did not have a formal QAPI plan in place. The Administrator admitted to not having a recent QAPI plan and lacked record-keeping of meeting minutes, which are essential for tracking and addressing deficiencies. The Administrator's focus was primarily on environmental issues, such as cleaning and pest control, rather than on the systemic issues identified in the survey. An audit tool for pharmacy services was provided, but it lacked specific details about the audits conducted, such as which medication or treatment cart was audited. Additionally, a document titled "BROOKSIDE CARE STRATEGIES 2022 QAPI PLAN" was outdated and did not reflect current practices. This lack of a structured and effective QAPI plan contributed to the facility's inability to address and prevent repeat deficiencies.
Deficient Call Light System in Facility
Penalty
Summary
The facility failed to provide a fully functional call light system for all resident rooms and bathrooms, affecting all 34 residents. Observations revealed that instead of a working call light system, residents were given hand bells or tabletop bells, which were often placed out of reach. Confidential interviews with residents and staff confirmed that the call light system had been inoperable for four to six months, and management was aware of the issue. Residents expressed difficulty in summoning assistance, with some having to yell or use personal telephones to call the facility for help. Employees also noted the challenge in identifying which resident needed assistance when a bell rang, as there was no light indicator. The report highlights that the facility's management was aware of the call light system's failure and had not yet signed a contract for its replacement or repair, despite being informed that the system was completely down and needed replacement. The facility's policy, revised in January 2023, emphasized the importance of providing residents access to a call light and ensuring the system's proper functioning. However, the facility's inaction in addressing the broken call light system led to residents relying on inadequate manual bells, which were not suitable for all residents, particularly those with physical limitations.
Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to ensure that the most recent survey results were readily accessible to residents and their representatives. During a review of the facility's survey binder, it was found that the most recent survey included was dated 11/27/23, and all other surveys were dated prior to this. The binder was located behind the nurse's station, and signage indicated that individuals should ask for the survey binder. The Administrator, during an interview, stated that he believed only annual surveys needed to be included in the binder and was unaware that complaint surveys were also required. However, records from the Indiana Department of Health showed that complaint surveys were conducted on several dates after 11/27/23, which were not included in the binder. The facility's policy indicated that a copy of the most recent standard survey, including any subsequent surveys and follow-up reports, should be maintained in a location frequented by residents, such as the main lobby or resident activity center.
Failure to Implement Grievance Process According to Policy
Penalty
Summary
The facility failed to implement a grievance process according to its policy for resident and resident representative concerns. During a record review, it was found that the most recent grievance was filed several months prior, indicating a lack of documentation for any grievances or complaints since that time. The Social Services Director (SSD), who was identified as the grievance official, stated that any complaints or concerns were resolved immediately, and therefore, there was no need to document them on a grievance form. The facility's current policy, revised in April 2017, requires that all grievances, complaints, or recommendations concerning resident care be considered and responded to in writing. The policy also mandates that upon receipt of a grievance, the Grievance Officer must review and investigate the allegations and submit a written report to the Administrator within five working days. However, the SSD's practice of resolving issues immediately without documentation contradicts the facility's policy, leading to a deficiency in the grievance process.
Inadequate Infection Control Program Implementation
Penalty
Summary
The facility failed to develop and implement an effective infection control program. During a record review, it was found that the Infection Control Binder's Infection Log and color-coded mapping were only completed using the antibiotic Order Listing Report, which was not printed until after the survey began. This report was printed for several months, from March to September 2024, indicating a lack of prior tracking and trending of resident infections. The Infection Preventionist, who had only been in the position since early September and was splitting her time between two locations, was unaware of who held the position before her and had only recently filled out the Infection Log pages based on the antibiotic orders. The facility's policy on infection prevention and control was undated and indicated the need for an infection control program to prevent and control infections, but this was not effectively implemented.
Facility Fails to Provide Chairs in Resident Rooms
Penalty
Summary
The facility failed to provide safe and comfortable chairs in resident rooms, impacting all 34 residents. During confidential interviews, several residents expressed a desire for chairs in their rooms, indicating they often had to sit on their beds or tables. Observations confirmed the absence of chairs in multiple resident rooms on different dates. One resident mentioned the difficulty of bringing a chair from the dining room, while another expressed the need for a chair for guests, who otherwise had to sit on the bed with the resident. The facility's Administrator was unaware of the need to provide chairs in resident rooms and cited a lack of space as a reason for their absence. The Director of Nursing (DON) confirmed that the facility did not have a policy regarding furniture in resident rooms. This lack of awareness and policy contributed to the deficiency, as residents had not explicitly requested chairs, and the facility had not proactively addressed this need.
Failure to Develop Baseline Care Plan for Pressure Ulcer Risk
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident who was admitted with a risk for pressure ulcers. The resident, who had diagnoses including pain in the right lower leg, alcohol abuse in remission, and stage 3 chronic kidney disease, was admitted to the facility, but her clinical record lacked a baseline care plan. During interviews, it was revealed that a Braden Scale risk assessment, which is crucial for determining pressure ulcer prevention interventions, was not completed upon admission. The Director of Nursing confirmed that a baseline care plan was not developed for the resident at the time of admission, which is a requirement according to the facility's policy on pressure ulcer/wound care.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to assess a resident for pressure ulcer risk upon admission and did not implement timely interventions to prevent pressure ulcers. Resident 31, who was admitted with no skin issues, was not assessed using the Braden Scale until seven weeks after admission, despite being at risk for pressure ulcers. The resident required substantial assistance for various activities of daily living and was dependent on staff for repositioning, yet the facility did not have a consistent plan in place to manage this risk. Observations revealed that the resident was often found in bed on her back, with her heels resting against the mattress, which contributed to the development of deep tissue injuries on both heels. The facility's records showed a lack of weekly skin assessments and documentation of the resident's heel wounds, which were first noted by a Nurse Practitioner on 7/2/24. Despite physician orders for interventions such as skin preparation wipes, floating heels, and the use of a low air loss bed, these measures were not consistently documented or observed in practice. Interviews with staff indicated a lack of awareness and implementation of a turn and reposition schedule for the resident. The resident was cooperative with care but was not consistently provided with pressure relief boots, which were only introduced after the development of pressure ulcers. The facility's policy required documentation of preventative measures and equipment used, but this was not adhered to, contributing to the resident's condition worsening over time.
Failure to Implement Behavioral Interventions for Resident
Penalty
Summary
The facility failed to implement care plan interventions for a resident, identified as Resident 13, who was experiencing behavioral difficulties in a common area. Resident 13, diagnosed with schizophrenia, profound intellectual disability, generalized anxiety disorder, and borderline personality disorder, exhibited severe cognitive impairment and displayed physical behavioral symptoms. The care plan for Resident 13 included interventions such as ensuring space for the resident, offering to take the resident to a quiet area, and assisting with removing peers from the area during behavioral episodes. However, these interventions were not implemented during an incident where Resident 13 became out of control, causing fear among other residents. On the evening of the incident, Resident 13 engaged in disruptive behaviors, including pounding on walls, throwing furniture, and punching holes in the wall. Despite the care plan's directives, staff did not attempt to remove Resident 13 or his peers from the area, nor were any behavioral interventions documented in the clinical record. Interviews with staff members, including RN 17 and CNA 18, revealed that they witnessed the resident's aggressive actions but did not take steps to de-escalate the situation or ensure the safety of other residents. The facility's security cameras, which could have provided additional oversight, were reportedly not functioning properly during the incident. The facility's failure to follow the established care plan and implement appropriate behavioral interventions resulted in a deficiency. The lack of action by staff members during Resident 13's behavioral episode, combined with the absence of documented interventions, highlights a significant oversight in managing the resident's care. The facility's policy on behavior management emphasizes the need for appropriate intervention and treatment plans, which were not adhered to in this case.
Failure in Narcotic Count and Reconciliation
Penalty
Summary
The facility failed to ensure proper shift-to-shift narcotic count and reconciliation for two medication carts, the West cart and the East cart. During a medication storage observation, it was found that the Narcotic Count Sheet for the West cart lacked shift-to-shift count and reconciliation signatures for numerous dates in August and September 2024. Specifically, there were missing narcotic card counts and reconciliation signatures for various shifts, indicating a failure to document the transfer of controlled medications between staff members. Interviews with QMA 6 revealed that the narcotic count was supposed to be completed when the medication cart was transferred from one employee to the next. Similarly, the East medication cart also showed deficiencies in narcotic count and reconciliation. The Narcotic Count Sheet for this cart lacked signatures for several dates in August and September 2024. Interviews with QMA 5 confirmed that the narcotic count sheet was intended to be completed by both the oncoming and off-going nurses at shift change. The Director of Nursing indicated that the expectation was for staff to complete the narcotic count sheet in full at the start and end of each shift. The facility's policy on controlled substances required a physical inventory of controlled medications at each shift change, conducted by two licensed clinicians and documented on an audit record.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as observed during a survey of two medication carts. On the West medication cart, a Levemir insulin vial was found with an open date, but it was not discarded after the 30-day period as indicated by the Director of Nursing (DON). Additionally, 66 single packets of 4% lidocaine patches were found without resident identifiers or manufacturer container information. The Qualified Medication Aide (QMA) accompanying the surveyor was not insulin certified and unaware of the insulin's shelf life. The DON confirmed that opened insulin should be discarded after 30 days. On the East medication cart, a Humalog insulin Kwikpen was found without an open date, contrary to the facility's policy that requires insulin to be dated upon opening and discarded after 28 days. Interviews revealed that the lidocaine patches were stock medications ordered from a supply company and not individually labeled for residents, as only two residents used them. The facility's policies require medications to be stored in their original containers with clear labeling, including expiration dates and resident information, which was not adhered to in these instances.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the Indiana Department of Health concerning a resident, identified as Resident C, who reported being touched inappropriately by another resident, Resident D, in a common area. The incident was reported to the facility's Administrator on the same day it occurred. The Administrator conducted an investigation, which included reviewing video surveillance, and concluded that the allegation was unsubstantiated. Despite the facility's investigation, the alleged abuse was not reported to the Indiana Department of Health as required. The Administrator believed that the allegation did not need to be reported due to Resident C's history of making false allegations and the results of the facility's investigation. However, the facility's policy on abuse prevention and prohibition, as well as the Indiana Department of Health's guidelines, require that any incident involving unwanted sexual contact be reported to the appropriate authorities. The failure to report this incident was identified as a deficiency during the survey.
Inadequate Investigation of Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an alleged sexual abuse incident involving Resident C, who reported that a male resident, Resident D, touched her breast without consent. The incident was reported to the Social Services Director (SSD) and the Administrator, but the facility's investigation was found lacking. The investigation did not include essential details such as the time the information was reported, the time the alleged event occurred, and the time the follow-up was completed. Additionally, the investigation did not include a skin assessment of Resident C or interviews with other staff or residents who might have witnessed the event. Resident C's clinical record indicated diagnoses of general anxiety, moderate major depressive disorder, and post-traumatic stress disorder. Despite being cognitively intact, the record lacked documentation of the alleged sexual abuse during the specified period. Resident D's clinical record showed diagnoses of major depressive disorder, generalized anxiety disorder, and bipolar disorder, with a care plan addressing hypersexuality and allegations of inappropriate touching. However, the facility's investigation did not include interviews with other residents or staff, which could have provided additional insights into the incident. The facility's policy on abuse prevention and prohibition required a thorough investigation of any abuse allegations, including documenting the time, date, place, individuals present, and a description of the event. However, the investigation was halted due to a lack of evidence from the limited surveillance footage provided by the corporate office. The Administrator believed the facility followed state guidelines, but the investigation did not meet the facility's policy requirements, as it lacked comprehensive interviews and documentation.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information in a readily accessible and readable format for residents and visitors over a period of three consecutive days. Observations on 9/22/24, 9/23/24, and 9/24/24 revealed that no direct care staffing numbers were posted. During an interview on 9/24/24, the Director of Nursing (DON) indicated that the schedule book, which contained handwritten staff schedules, was kept at the nurse station and used for staff posting. However, this did not meet the requirement of posting staffing numbers in a prominent location. The Administrator was unaware of the missing staff posting and also referred to the schedule book for daily staff schedules. The facility's policy, revised in July 2016, required that staffing numbers be posted within two hours of each shift's start in a clear and accessible manner, which was not adhered to during the survey period.
Facility Fails to Honor Resident's Right to Return After ER Visit
Penalty
Summary
The facility failed to honor a resident's right to return to the facility after an emergency room visit following a resident-to-resident altercation. The resident, who had a history of mild cognitive impairment, mood disorder, and other health issues, was involved in a physical altercation where he stomped on another resident's head. Despite undergoing psychiatric and social work evaluations at the hospital, which noted no significant behavioral changes, the facility refused to accept the resident back, citing discomfort with his behaviors. The facility discharged the resident to a homeless shelter located 61 miles away without providing a thirty-day written notice or an opportunity for the resident to appeal the transfer. The resident was given his belongings, medications, and a small amount of cash, but the shelter had no record of his admission. The facility's actions did not align with their discharge policy, which requires documentation of the resident's needs not being met or the resident posing an immediate danger to others. The resident was later found by police on a sidewalk in the same city as the facility and was hospitalized for dehydration and acute kidney injury. The facility's failure to provide a safe discharge plan and to document the necessity of the discharge placed the resident at risk of harm, as evidenced by his subsequent hospitalization.
Improper Discharge of Resident Following Hospital Visit
Penalty
Summary
The facility failed to adhere to its policies regarding the return of a resident following a hospital visit, resulting in a deficiency. Resident C, who had a history of mild cognitive impairment, alcohol use, cerebral infarction, mood disorder, cocaine abuse, and epileptic syndrome, was involved in a physical altercation with another resident. Following this incident, the police were called, and Resident C was taken to the emergency department for evaluation. Despite the hospital's assessment that the resident could return to the facility, the facility refused to accept him back, citing concerns about his behavior. The facility did not provide Resident C with a thirty-day written notice of discharge, nor did it offer him the opportunity to appeal the discharge decision. Instead, the Administrator arranged for the resident to be taken to a homeless shelter, which was later found to have no record of his admission. The resident was subsequently left at a hotel 26 miles away from the facility, without proper documentation or consideration of his needs and choices. This action was taken without ensuring a safe and appropriate discharge location, as required by the facility's policies. The failure to follow proper discharge procedures and provide adequate notice placed Resident C at risk, as evidenced by his subsequent hospitalization for dehydration and acute kidney injury after being found on a sidewalk. The facility's actions were inconsistent with its own policies, which require a documented reason for discharge and consideration of the resident's best interests in determining a discharge location.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired resident, Resident D, from physical abuse by another resident, Resident C, who was known to have a history of aggressive behavior. On the evening of August 15, 2024, Resident D was found on the floor of Resident C's room with a head laceration and bruising, requiring emergency treatment and six sutures. Resident C admitted to stomping on Resident D's head multiple times after being woken up by him. This incident was reported to the Indiana Department of Health and involved local police intervention. Resident C had a documented history of verbal and physical aggression, with care plans indicating potential triggers and interventions to manage his behavior. Despite these measures, Resident C's aggressive tendencies persisted, as evidenced by multiple incidents of verbal and physical behaviors recorded in a Behavior Management Monthly Review. Staff interviews revealed that Resident C was often agitated by noise and proximity to others, and while some interventions were in place, they were not always effective in preventing aggressive outbursts. Resident D, on the other hand, was known to wander due to impaired safety awareness and severe cognitive deficits. His care plan included interventions to redirect him from wandering and entering other residents' rooms, but these measures were insufficient to prevent the incident with Resident C. Staff interviews confirmed that Resident D frequently wandered into other rooms and was easily redirected, yet there was a lack of supervision to ensure his safety, ultimately leading to the altercation with Resident C.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications received from the contracted pharmaceutical company were labeled appropriately for one of the nine residents reviewed for medication use. During a medication administration observation, two bottles of oral Nystatin were found in the medication cart without proper labeling, including missing resident identifiers and instructions. Specifically, one bottle lacked the resident's name, dosage, and time/frequency for administration, and had a sticker with an opened date. The second bottle also lacked the resident's name, dosage, and time/frequency for administration. The RN present during the observation was unable to identify to whom the medications were prescribed, noting that two residents were currently prescribed Nystatin, and no other bottles were available in the cart. The Director of Nursing (DON) was also interviewed and indicated a lack of knowledge regarding to whom the medication was prescribed and how it was received from the pharmacy without appropriate labels. The facility's current policy, titled Provider Pharmacy Requirements, mandates that all prescription medications have labels with specific information, including the resident's name and directions for use. This deficiency was related to a specific complaint, highlighting a failure in adhering to the facility's established procedures for medication labeling.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Muncie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cardinal Care Strategies | 1.7 mi | ★★★★★ | 30 | 3 |
| Waters Of Muncie, The | 1.7 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Muncie | 2.4 mi | ★★★★★ | 30 | 0 |
| Waters Edge Village | 2.7 mi | ★★★★★ | 5 | 0 |
| Envive Of Muncie | 3.4 mi | ★★★★★ | 12 | 0 |
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