Byron Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Wayne, Indiana.
- Location
- 1661 Beacon Street, Fort Wayne, Indiana 46805
- CMS Provider Number
- 155364
- Inspections on file
- 30
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Byron Health Center during CMS and state inspections, most recent first.
Surveyors found that dietary staff failed to follow facility policies for food labeling, storage, and sanitation, affecting all residents receiving meals. Multiple food items in freezers, refrigerators, dry storage, and on countertops were left open to air, lacked lids, and were not labeled with open or expiration dates, including frozen items, bread products, cereals, and seasonings that had been removed from original packaging. In addition, a set of keys was left on the steam table serving area, the handwashing sink contained visible debris, and the grill and grill foil had significant black buildup despite documentation that these surfaces had recently been cleaned. The Dietary Manager confirmed that these conditions did not comply with the facility’s standards for labeling, covering, and cleaning food and food-contact surfaces.
The facility failed to maintain proper kitchen sanitation and food labeling for all residents receiving meals, with surveyors observing multiple open and undated food items, including frozen products, dry goods, and bread, as well as seasoning stored without a lid. Similar issues had been cited previously under F812 for sanitation, open food items, and lack of labeling and dating. The ED reported that she and an assistant conducted undocumented kitchen observations and that a committee had been working on food temperatures, labeling, dating, and cleanliness, but no related policy was provided at survey exit.
Two residents with neurological impairments and contractures did not consistently receive prescribed cervical collars and a mechanical back/cervical splint during bedrest and meals. One resident, ordered to wear a soft cervical collar in bed and for all meals for neck contracture management, was repeatedly observed without the collar, which was found on the bedside stand, and her care plan and CNA Kardex lacked instructions for its use or refusal despite documentation that she preferred wearing it. Staff gave conflicting accounts about whether the collar was still in use, and there was no documentation of refusals as required by facility policy. Another resident, ordered to wear a cervical brace during all meals, was repeatedly observed with her head leaning to one side, without the brace, and not eating, while CNAs reported the brace’s Velcro failed and her head slipped out despite repeated attempts to reposition and reapply it. Therapy and restorative staff acknowledged ongoing issues with the brace, missed reassessment, and lack of reported concerns, contrary to facility policy requiring regular assessment and reporting of problems with assistive devices.
The facility failed to complete post-fall neurological assessments as described by staff practice for three residents with conditions including dementia, epilepsy, abnormal posture, and diabetes. After unwitnessed and other falls, required neuros at specified intervals and every shift for 72 hours were repeatedly missing across multiple days and shifts, despite care plan directives to follow the fall protocol. The DON and an LPN described a detailed neuro check schedule after falls, but record reviews showed numerous omitted assessments and entire periods with no documented neuros, even though the written falls protocol required assessment and documentation of neurological status.
A resident with Alzheimer’s disease, anxiety, depression, and significant cognitive impairment expressed suicidal ideation to a volunteer, stating she had nothing to live for and wanted to kill herself. The resident’s care plan required immediate supervisor notification and redirection for suicidal comments, and facility policy required immediate reporting to the nurse supervisor, continuous supervision, completion of a suicide risk assessment, provider notification, and documentation. The volunteer documented the statement on a 1:1 visit log and verbally reported it to staff on an adjacent unit, but nursing staff on the resident’s unit were unaware of the incident, the Life Enrichment Specialist read the log days later and did not report it, and no further assessment, provider notification, or documentation of follow-up occurred.
A resident with altered mental status and diabetes had a portable urinal repeatedly observed over several days hanging, still containing urine, from a trash bin that also held other discarded items, and later placed on a table with personal items. The CNA acknowledged this as an infection control concern and reported uncertainty about where to store the urinal, while also noting the resident’s preference to keep it close due to frequent bathroom use. The DON stated that urinals were expected to be cleaned after use and stored on the back of the toilet, and that any preference to keep a urinal at bedside should be reflected in the care plan, but this was not documented for this resident despite a facility policy outlining proper bedside urinal management and care plan notation.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unsupervised, traveling several miles and crossing busy streets before being returned by police. The resident's care plan did not address her risk for elopement or include interventions for wandering, and staff were unaware of her absence until notified by an external party. No elopement risk assessments were completed despite documented wandering behaviors.
Surveyors observed multiple failures in kitchen sanitation and food handling, including unlabeled and undated opened food items, expired and uncovered food, improper storage of scoops in dry goods, and inadequate cleaning of kitchen surfaces and equipment. Baking pans were stacked while still wet, and food items were left open to air exposure. These deficiencies affected nearly all residents served by the kitchen.
A resident with diabetes and dementia received a subcutaneous injection of Trulicity from an LPN in a common dining area while eating breakfast, requiring the resident to expose his abdomen in front of others. Staff interviews and facility policy confirmed that medication administration in public areas during meals is not permitted due to dignity and privacy concerns.
A resident's personal and medical information, including medication list and vital signs, was left visible on an unattended computer screen and paper worksheet on a medicine cart in a hallway. The information was accessible to staff and residents passing by, and the RN later acknowledged not securing the records as required by facility policy.
Two residents with significant medical conditions were transferred to the hospital without documentation that the facility's bed hold policy was explained to them or their families. The DON confirmed that this notification should have been documented in the progress notes, in accordance with facility policy.
The facility did not ensure accurate assessment and documentation for two residents with complex medical needs. One resident with chronic neurological issues had repeated documentation of normal pupil response despite observed unequal pupils, and the care plan did not address this known condition. Another resident with acute respiratory conditions did not receive required shift-by-shift respiratory assessments as ordered, with several shifts missing documentation of breath sounds. Staff interviews confirmed gaps in awareness and adherence to assessment protocols.
A resident with chronic respiratory failure and cognitive impairment was found on two occasions with unbagged oxygen tubing left out and the oxygen concentrator running while not in use. The resident was also observed in bed with labored breathing, poorly positioned, and unable to access her oxygen, with staff confirming she could not have moved the tubing herself. Facility policy requiring proper oxygen application and storage was not followed.
A resident at high risk for falls was left unattended in a shower chair by a CNA, leading to an unwitnessed fall. The resident, with a history of traumatic brain injury and quadriplegia, began foaming at the mouth, prompting the CNA to leave the room to seek help. Upon return, the resident was found on the floor. The facility's policy lacked specific interventions for high fall risk residents.
Improper Food Labeling, Storage, and Kitchen Sanitation in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in food labeling, storage, and protection from contamination affecting all 103 residents who received food from the facility’s kitchen. During an initial kitchen observation, multiple food items in the walk-in freezer, refrigerator, dry storage, countertop, and reach-in freezer were found open to air, without lids, and lacking open or expiration dates. These included a bag of frozen chips, a box of cinnamon rolls, an open container of beef base without a lid, elbow macaroni removed from original packaging and placed in an unlabeled plastic container, multiple bags of sliced bread and buns in various locations, and an open box of frozen hamburgers. On the spice rack, an open container of dill weed seasoning without a lid was observed, and on the back cabinets, Raisin Bran and Trix cereals had been removed from their original packaging and placed into plastic containers without open dates. The Dietary Manager stated that facility practice was to label and date all items when opened and to follow manufacturer expiration dates when items remained in original packaging, and confirmed that the observed items were not labeled or dated and that food should not be left open to air. Surveyors also observed sanitation and cleanliness issues in the kitchen environment. A set of keys was found sitting on the steam table serving area, the handwashing sink contained brown chunks and white debris, and the grill had black buildup between and underneath the grates, with a large accumulation of black residue on the grill foil. A review of the facility’s weekly cleaning list showed that the grill foil, grill grates, shelving, grill, and stovetop had been documented as cleaned on the two days prior to the observation. The Dietary Manager attributed the black buildup on the grill to cooking breakfast and suggested that staff may have had food on their hands when using the handwashing sink, and also acknowledged that keys should not have been left on the kitchen serving area. These conditions were inconsistent with the facility’s written policies requiring all foods stored in refrigerators, freezers, and dry storage bins to be covered, labeled, and dated, and requiring food service equipment and food-contact surfaces to be cleaned and sanitized at a frequency that prevents contamination.
Repeat Failure to Maintain Kitchen Sanitation and Food Labeling
Penalty
Summary
The facility failed to effectively implement interventions to maintain kitchen sanitation for all 103 residents who consumed food prepared in the kitchen. During a kitchen observation, surveyors found multiple food items improperly stored and not dated, including a bag of frozen chips and cinnamon rolls in the freezer open to air with no open dates, beef base without an open date, and elbow macaroni in a clear bin without a date. Additional undated bread products included white bread, whole wheat bread, hamburger buns, and sub buns, and dill weed seasoning was observed without a lid and open to air. These sanitation and food labeling issues were similar to those cited under F812 in a prior recertification survey, which had identified problems with maintaining sanitation, open food items, labeling of food, and dating of opened food. In an interview, the Executive Director reported that she and the Assistant Executive Director conducted various observations of the main kitchen and neighborhood kitchenettes but had no documentation of these observations. The Executive Director stated that the committee had been working on food temperatures, labeling, dating, and cleanliness since the previous April and noted there had been turnover among dietary aides, which she believed had corrected the problem until the most recent annual survey results. No policy related to these issues was provided at the time of survey exit.
Failure to Provide and Maintain Prescribed Cervical Collars and Splints for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and maintain prescribed cervical collars and a mechanical back/cervical splint for two residents with significant neurological and musculoskeletal impairments. For one resident with a history of cerebral infarction, right middle cerebral artery occlusion, and left-sided hemiplegia/hemiparesis, surveyors repeatedly observed her in bed without the ordered soft cervical collar in place, despite a physician’s order that she wear the collar while in bed and for all meals for neck contracture management. The collar was seen on the bedside stand during one observation, and the resident’s care plan and CNA Kardex contained no instructions regarding use or refusal of the collar. The NP’s earlier progress note documented that the resident liked wearing the collar and wanted to wear it more frequently than ordered, and there were no subsequent notes documenting refusal or discontinuation. Staff interviews further showed inconsistent understanding and implementation of the collar order for this resident. A CNA reported believing the collar had been discontinued after a trial for meals only, stating it was unsuccessful and that she understood it was no longer in use. The DON stated the collar had been used when the resident was eating meals consistently, but that it was not being used because the resident was now being offered food for pleasure only and was expected to receive a feeding tube. The DON also stated the collar was in the laundry because it was dirty and acknowledged that refusals should have been documented and that frequent refusals should have triggered re-evaluation of the device. The Director of Therapy confirmed the collar had been implemented for a right-sided neck contracture and that the resident initially wanted to wear it more often, and indicated that documentation of refusals was the responsibility of nursing. The facility’s policy on braces and assistive devices required documentation of refusals, follow-up actions, and care plan updates addressing device type, application instructions, monitoring guidelines, and specific risks, which were not reflected in the record. For a second resident with diagnoses including unspecified intracranial injury, left-sided hemiplegia, and traumatic subarachnoid hemorrhage, surveyors repeatedly observed her during meals with her head leaning to the left, without the prescribed mechanical back/cervical splint in place, and with full or covered meal trays that she was not eating. Her care plan identified an ADL self-performance deficit and included an intervention for application of a cervical/back splint during meals and removal afterward. Physician orders directed that she wear a cervical brace during all meals, angled approximately 30 degrees in extension with a towel under the brace. However, the most recent MDS did not indicate use of splints or braces, and staff interviews revealed ongoing problems with the brace’s fit and function that were not effectively addressed. CNAs reported that the resident should have had the brace on but that her head repeatedly slipped out of it, even after attempts to reposition her and reapply the brace, and one CNA stated she was unsure whether the NP or therapy had been notified. Another CNA described the Velcro on the brace releasing and the resident sliding in her seat so that the brace could not support her head, and indicated she had not been instructed on alternative interventions if the brace was ineffective and was unaware of any notification to NP or therapy. The Director of Therapy stated that therapy was initially responsible for the brace and that, after discharge, restorative nursing managed issues, with therapy performing screenings every three months; she acknowledged awareness that the Velcro continued to come undone but did not describe additional actions to ensure the brace was safe and properly fitting. The restorative nurse reported that Velcro had been replaced earlier in the month and that staff had not reported ongoing issues. The DOT later stated that the resident had been missed for a scheduled reassessment that should have occurred approximately three months after the last assessment and that she was on a list for reevaluation while therapy awaited an order. The facility’s policy required assessment of braces and assistive devices on admission, with changes in condition, and periodically as part of the care plan process, with nursing staff reporting changes in mobility or tolerance and reassessment quarterly with MDS review, which was not consistently carried out for this resident.
Failure to Complete Post-Fall Neurological Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete neurological assessments after falls in accordance with its described practice for multiple residents. For unwitnessed falls, an LPN and the DON both stated that staff were to assess the resident for injuries, determine the cause of the fall, initiate neurological checks every 15 minutes for the first hour, then hourly for four hours, and then every shift for 72 hours, along with provider and family notification, skin and post-fall assessments, dehydration assessment, and documentation. Record review for a resident with epilepsy, dementia, and diabetes showed missing neurological assessments following an unwitnessed fall on specific dates and times, including incomplete checks on the night and subsequent shifts. Another resident, also with epilepsy, dementia, and diabetes and care planned as being at risk for falls with an intervention to follow the facility fall protocol, had multiple missing neurological assessments after falls. These included missing second-shift neuros on several consecutive days, missing neuros at multiple specified times on another date, and absent first- and second-shift neuros on a subsequent date, as well as missing neuros at designated early-morning times and no documented every-shift neuros for 72 hours on three days. A third resident with dementia, abnormal posture, and diabetes had no neurological assessments located by the DON for multiple falls over several days, and neuros were also missing for three days following a fall later in the year. The facility’s written Falls Clinical Protocol required assessment and documentation of neurological status and related factors after falls but did not specify the frequency of neurological assessments.
Failure to Investigate and Respond to Resident’s Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to investigate and respond to a resident’s verbalization of suicidal ideation as required by the resident’s care plan and facility policy. The resident had diagnoses of Alzheimer’s disease, anxiety, and depression, and a current MDS showed significant cognitive impairment with a BIMS score of 4. The resident’s care plan for depression with a history of suicidal ideation directed staff to immediately notify a supervisor and redirect the resident when suicidal comments were made. On 3/9/2026, a progress note documented that the resident told a volunteer she had nothing to live for and wanted to kill herself, and a 1:1 visit log from that same encounter recorded the same statement. However, there were no additional progress notes or documentation showing that the suicidal ideation was further assessed, that the care plan interventions were implemented, or that the provider was notified. Interviews revealed multiple communication and follow-through failures. The DON stated that any resident verbalizing suicidal ideation should be asked if they had a plan to harm themselves, the care plan should be reviewed and followed, and the resident might be sent for inpatient psychiatric care if appropriate. A QMA who regularly worked on the resident’s unit reported she was not aware of the suicidal statement made on 3/9/2026, although she recalled the resident had made suicidal remarks upon admission months earlier. The Life Enrichment Specialist stated that volunteers complete visit logs and that she entered the 3/9/2026 log into the computer on 3/18/2026, at which time she read the suicidal statement but did not report it as she should have. The volunteer reported that after hearing the suicidal statement, he offered supportive words and then reported it to staff on an adjacent unit when he could not immediately find the unit nurse. The facility’s “Suicide Threats” policy required immediate reporting of any suicide threats to the Nurse Supervisor, continuous supervision of the resident, completion of a Columbia Suicide Severity Rating Scale, reporting findings to the provider, following any provider orders, and documenting the situation, but these steps were not carried out for this resident’s suicidal verbalization.
Improper Storage and Handling of Bedside Urinal
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to improper storage and handling of a portable urinal for one resident. On multiple observations over three consecutive days, the resident was seen sitting in a recliner with a portable urinal containing yellow liquid hanging by its handle on a trash bin in the room. On one of those days, the trash bin also contained a glove, a plastic drinking cup, a piece of folded paper, and three paper towels, while the urinal remained hanging from the bin. In a later observation the same day, the urinal was seen sitting on top of the resident’s table alongside three remote controls and a piece of folded paper. The urinal had been dated several days earlier, and there was no indication it had been emptied and cleaned between observations. Record review showed the resident had diagnoses including altered mental status and diabetes mellitus. The resident’s current care plan did not indicate that a urinal was to be kept at the bedside or within immediate reach while seated in a recliner. During interview, the CNA caring for the resident acknowledged that hanging the urinal on the trash can was an infection control concern and stated she was unsure where to place the urinal because the resident’s table had items on it, while also noting the resident liked to have the urinal close by due to frequent bathroom use. The DON stated that staff were expected to clean the urinal after use and store it on the back of the toilet when not in use, and that clean urinals should be stored there. The DON also stated that the care plan should reflect if a resident preferred to keep a urinal close by, but this preference was not documented for this resident. The facility’s policy indicated that if a resident keeps a urinal at bedside, it should be checked frequently, emptied and cleaned as necessary, documented on the care plan, and stored on a paper towel on the bedside stand with a cover when not in use.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with a history of severe cognitive impairment and high risk for wandering was able to leave the facility unsupervised and travel approximately three miles, crossing heavily trafficked streets, before being returned by local police. The resident, who had a BIMS score of 3/15 indicating severely impaired cognition and diagnoses including an unspecified mental disorder and chronic obstructive pulmonary disease, resided on an unsecured unit and had a documented history of wandering within the facility. Despite these risk factors, the resident's care plan did not address her ability to exit the facility alone, did not include interventions for wandering, and did not specify how often her whereabouts should be checked. On the day of the incident, the resident was observed by the facility's CFO exiting and re-entering the building multiple times in the morning, with the final exit occurring at 10:03 AM. No staff member was aware that the resident had left the facility, and her absence went unnoticed until the CFO received a call from the resident's friend at 12:49 PM, informing her that the resident was at her former apartment and that the police were returning her to the facility. Interviews with staff revealed that the last known sighting of the resident was around 9 AM, and staff did not realize she was missing until notified by an external party. The resident did not sign out or have a family member or friend accompany her, as required for a leave of absence. Review of the resident's records showed that while she was assessed as high risk for wandering, no elopement risk assessments were completed, and her care plan lacked specific interventions for her wandering behavior. Nursing notes prior to the incident documented episodes of the resident being lost within the facility and expressing intentions to leave, but these behaviors were not addressed with targeted interventions. The facility's policy required assessment and interventions to prevent elopement, but these were not implemented for this resident prior to the incident.
Deficient Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to maintain proper kitchen sanitation and food handling practices, as evidenced by multiple observations during a survey. Opened food items, such as a container of ice cream and chef salads, were found in the kitchen without being labeled or dated. Several food items in the freezer, including hamburger patties, chicken strips, and French fries, were left open to air exposure and not dated when opened. An open box of popsicles was observed past its expiration date, and a cart containing expired fruit and cake was not disposed of as required. Additionally, scoops for flour and sugar were stored inside the bins, contrary to policy, and the fruit and cake on the cart were not individually covered and appeared dry. Sanitation issues were also noted, including a shelf next to the fryer with a large amount of oily liquid and debris, and multicolored streaks and splatters on the freezer doors. Baking pans were found stacked while still wet, with clear liquid dripping from them, indicating they were not thoroughly air dried before storage. The Dietary Manager confirmed that these practices did not align with facility policies, which require all food to be covered, labeled, and dated, and all equipment to be sanitized and properly air dried. These deficiencies affected 95 of 96 residents who were served food prepared in the kitchen.
Medication Administration in Common Area Compromises Resident Dignity
Penalty
Summary
A deficiency occurred when a nurse administered medications, including a subcutaneous injection of Trulicity, to a resident in a common dining area while the resident was eating breakfast. The resident, who had diagnoses of type 2 diabetes, chronic gingivitis, and unspecified dementia, was observed pulling up his shirt to expose his abdomen for the injection in the presence of others. The resident's care plan did not indicate any preference for receiving medications in common areas. Interviews with staff confirmed that it was not permitted to administer medications in the common area during meals due to concerns about resident dignity and the expectation that residents should enjoy their meals without interruption. Facility policy also required staff to maintain resident privacy and dignity during treatment procedures, including protecting bodily privacy. The administration of the injection in a public setting was not consistent with these policies.
Failure to Protect Resident Health Information Privacy
Penalty
Summary
A deficiency occurred when a computer screen displaying a resident's name, picture, medication list, and other personal health information was left open and visible on top of a medicine cart in a hallway. Additionally, a paper worksheet containing vital signs and other health information for multiple residents was left on top of the cart. Both the computer screen and worksheet were accessible in an area where staff and residents were passing by, making the information visible to unauthorized individuals. The incident was observed during routine activities, including medication administration and meal assistance. The resident involved had diagnoses including cerebral palsy, abnormal weight loss, dysphagia, and altered mental status, with a BIMS score indicating cognitive impairment. During interviews, the RN acknowledged forgetting to lock the computer screen and failing to turn over the worksheet to protect resident information. The DON confirmed that facility policy requires computer screens to be locked and paper records to be secured when unattended, in order to maintain confidentiality of resident information.
Failure to Provide Bed Hold Policy Notification Prior to Hospital Transfer
Penalty
Summary
The facility failed to provide required documentation or notification regarding the bed hold policy to two residents prior to their discharge to the hospital. Resident 35, who had diagnoses including kidney failure, respiratory failure, and pneumonitis due to inhalation of food and vomit, was sent to the hospital without any documentation in the medical record indicating that the bed hold policy had been explained to her or her family. Similarly, Resident 47, with diagnoses of respiratory failure, dysphagia, and altered mental status, was also transferred to the hospital without evidence that the bed hold policy was communicated to him or his family. The Director of Nursing confirmed that the bed hold policy should have been documented in the progress notes and that residents or their representatives should always be informed of the policy prior to leaving the facility. The facility's current policy requires informing residents upon admission and prior to transfer for hospitalization or therapeutic leave about the bed hold policy, but there was no documentation to show this occurred for the two residents.
Failure to Accurately Assess and Document Neurological and Respiratory Status
Penalty
Summary
The facility failed to ensure accurate assessments and documentation for two residents with significant medical conditions. For one resident with a history of 6th abducent nerve palsy, 3rd oculomotor nerve palsy, and blepharoconjunctivitis, observations revealed unequal pupils—one dilated and nonreactive, the other normal—yet skilled charting repeatedly documented the pupils as equal, round, and reactive to light over several months. The resident's care plan addressed issues such as impaired vision and droopy eyelids but did not include interventions or monitoring for the known unequal pupils, despite this being a longstanding condition. Staff interviews confirmed a lack of awareness and proper documentation regarding the resident's pupil irregularities. For another resident with acute respiratory failure, pneumonitis, and dysphagia, physician orders required shift-by-shift documentation of breath sounds and related respiratory assessments following episodes of pneumonia and chest tube removal. However, multiple shifts lacked documentation of breath sounds as ordered, with specific dates noted where assessments were not completed. The DON acknowledged that the required assessments were missed. Facility policies required comprehensive neurological and respiratory assessments, but these were not consistently followed for the residents reviewed.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic respiratory failure and hypoxia. On two separate occasions, oxygen tubing was observed lying unbagged and not in use, with the oxygen concentrator left on and releasing oxygen while the resident was not present or not wearing the nasal cannula. Staff interviews confirmed that oxygen should be turned off when not in use and tubing should be bagged, but a bag was not available in the resident's room. The facility's policy required oxygen to be turned on only at the time of application and placed on the resident, but this was not followed. Additionally, the resident was found in bed with labored breathing, poorly positioned with her chin tucked to her chest, and without access to her oxygen tubing, which was out of her reach. The resident was cognitively impaired, required assistance with personal care, and had no documented refusal of care. Staff confirmed the resident could not have moved the tubing herself or accessed her wheelchair, indicating a lack of appropriate monitoring and intervention to ensure her respiratory needs were met.
Failure to Follow Fall Prevention Protocols for High-Risk Resident
Penalty
Summary
The facility failed to ensure fall prevention interventions were followed for a resident identified as being at high risk for falls. On the evening of the incident, a Certified Nurse Aide (CNA) assisted the resident in the shower. During the shower, the resident began to foam at the mouth and turned blue. The CNA left the resident alone in the shower chair to seek help, and upon returning with a Qualified Medication Aide (QMA), they found the resident on the floor of the shower. The incident was unwitnessed, and the resident was left unattended, which is against the facility's protocol for high fall risk residents. Interviews with staff members, including the Director of Nursing (DON), confirmed that the resident should not have been left alone in the shower chair. The facility's policy on falls did not specify interventions for high fall risk residents, which contributed to the deficiency. The resident's medical history included a traumatic brain injury, muscle weakness, and quadriplegia, and a recent fall assessment had indicated a high risk for falls. The care plan required assistance with transfers and showers, which was not adequately provided during the incident.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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