Carmel Health & Living Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Carmel, Indiana.
- Location
- 118 Medical Dr, Carmel, Indiana 46032
- CMS Provider Number
- 155181
- Inspections on file
- 38
- Latest survey
- November 13, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Carmel Health & Living Community during CMS and state inspections, most recent first.
A resident with left-sided weakness and requiring total assistance for bed mobility fell from bed during incontinence care when an LPN left the room, leaving a CNA alone to assist. The resident, weighing over 300 pounds, was on a bariatric bed that staff reported was too small. The resident rolled off the bed and sustained multiple skin tears and a subdural hematoma, requiring hospitalization.
A facility failed to ensure proper documentation of narcotic administration for two residents. RN 1 signed out narcotics in the count book but did not document their administration in the EMAR. Resident F, with severe pain conditions, had no PRN doses documented despite multiple sign-outs. Resident G, with severe dementia, had only one documented dose despite several sign-outs. All medications were accounted for, but RN 1 was terminated for not following policy.
The facility failed to follow physician orders for several residents, including inappropriate administration of insulin and blood pressure medications, delayed treatment for a UTI due to poor communication, and continued administration of discontinued medications. Additionally, daily weights and as-needed medications were not managed according to orders, highlighting significant lapses in care and communication.
A resident's mail from Medicaid was opened by facility staff without permission, despite the resident's explicit refusal to authorize such actions. The Business Office Manager opened the mail under corporate direction due to issues at other facilities. The facility lacked a specific mail delivery policy, and this action violated the resident's rights to privacy and confidentiality as outlined in the facility's Resident Rights policy.
The facility failed to ensure accurate and updated PASARR documentation for two residents. One resident's PASARR Level I did not list an antidepressant medication they were taking, while another resident's PASARR Level I failed to recognize a bipolar disorder diagnosis, missing the need for a Level II screen. The social service department was responsible for updating PASARRs, but the facility lacked a specific PASARR policy.
A facility failed to include a resident's insomnia diagnosis and related medications in their care plan. The resident, who had dementia and heart failure, was prescribed melatonin, trazodone, and Seroquel for insomnia. Staff interviews indicated that the social services department was responsible for updating care plans, but this was not done. The facility did not have a specific care plan policy and followed the RAI manual.
A resident was observed with a vape in their room, contrary to the facility's smoke-free policy. The CNA was unsure about the policy, and both the Unit Manager and Executive Director confirmed that vapes should not be in residents' rooms. The resident's medical history included opioid dependence and anxiety disorder.
The facility failed to administer the correct oxygen levels for two residents, with one receiving 3L instead of the ordered 2L, and another receiving 5L instead of 2L. Staff interviews confirmed the discrepancies, highlighting a lapse in verifying physician orders for oxygen administration.
The facility failed to ensure proper narcotic count procedures were followed, with numerous missing signatures from both on-coming and off-going staff in the 700-unit and 400-unit narcotic log count sheets. The facility's policy requires that outgoing and oncoming licensed nurses count and account for all scheduled drugs together and complete the Nurse's Narcotic Sign In/Sign Out sheet, which was not adhered to, leading to the observed deficiencies.
The facility failed to properly label, date, and store medications and supplements across three units, affecting two residents. An open insulin pen and liquid protein were found unlabeled, and medications were improperly stored. Two residents had unauthorized Diclofenac Sodium gel in their rooms, with one lacking a physician's order. Facility policies on drug storage and bedside medications were not followed.
A resident with a history of Alzheimer's and other conditions was observed with missing front teeth, and the facility failed to ensure her partial dentures were repaired or replaced. Despite a policy requiring prompt referral for dental services, there was no documentation of dental visits or attempts to address the issue, and staff interviews revealed confusion and lack of follow-up.
The facility failed to serve food at a safe and appetizing temperature for residents receiving room trays. Several residents reported that their food was cold, and a resident council meeting confirmed that room trays were sometimes cold. An observation showed that food items were served below the required temperature, and the Assistant Dining Services Supervisor acknowledged the need for reheating. The facility's policy requires reheating food to an internal temperature of 165 F for 15 seconds or replacing it.
The facility failed to maintain a safe and sanitary environment in five rooms, with issues such as exposed wires, ceiling stains, improperly fitted light switch covers, and food debris. A resident's room had persistent cleanliness issues, and opened wound supplies were left in another room. The maintenance supervisor and administrator were unaware of some deficiencies.
The facility failed to ensure that a resident was clinically appropriate to self-administer medications. An LPN left the resident alone with medication cups and a nebulizer vial within reach, without a documented assessment, physician's order, or care plan for self-administration. The facility's policy requires interdisciplinary team approval for self-administration, which was not followed.
An LPN failed to follow infection control practices by using her fingers to remove a medication capsule from the bottle for a resident with vascular dementia, chronic kidney disease, and insomnia, despite facility procedures prohibiting such actions.
Resident Fall During Incontinence Care Due to Inadequate Supervision and Bed Size
Penalty
Summary
A resident with a history of cerebral infarction, hemiplegia, and hemiparesis, who was dependent on staff for all activities of daily living and required a two-person physical assist for bed mobility, experienced a fall during incontinence care. The resident, who weighed over 300 pounds and had left-sided weakness from a previous stroke, was being cared for by a CNA and an LPN. During the care, the LPN left the room to obtain cream for the resident's excoriated skin, leaving the CNA alone with the resident. While the CNA was positioned on one side of the bed, the resident rolled over and fell off the bed onto the floor. The bed in use was a collapsible bariatric bed extended to 42 inches, but staff reported that the bed was still too small for the resident to fit comfortably. The resident was partially clothed and incontinent at the time of the fall. The CNA was unable to reach the other side of the bed to assist the resident as she rolled off. The fall was witnessed, and emergency services were called to assist in transferring the resident from the floor to a stretcher. As a result of the fall, the resident sustained multiple skin tears and was hospitalized with an eight-millimeter right frontal convexity subdural hematoma, as confirmed by a CT scan. The incident occurred while the resident was being prepared for dialysis, and the lack of adequate supervision and appropriate bed size contributed to the accident. The facility's documentation and interviews confirmed that staff did not remain with the resident throughout care and that the bed may not have been suitable for the resident's size.
Failure to Document Narcotic Administration
Penalty
Summary
The facility failed to ensure proper documentation and administration of narcotic medications for two residents, leading to a deficiency in pharmaceutical services. RN 1 was reported by a Qualified Medication Aide for potentially taking residents' narcotic medications, as she signed them out in the narcotic count book but did not document their administration in the residents' medical records. An investigation confirmed that all narcotic medications were accounted for, but RN 1 was terminated for not following the facility's policy and procedure. Resident F, diagnosed with conditions including malignant neoplasm of the rectum and cerebral infarction, had a physician's order for Oxycodone 10 mg as needed for severe pain. However, the resident's Electronic Medication Administration Record (EMAR) for November 2024 showed no documentation of PRN doses administered, despite the narcotic count sheet indicating multiple doses signed out by RN 1. A handwritten note confirmed that the resident had not missed any doses and had not complained of pain. Resident G, with diagnoses including severe vascular dementia and malignant neoplasm of the prostate, had a physician's order for Hydrocodone-acetaminophen 5-325 mg for pain. The EMAR for December 2024 documented only one PRN dose, while the narcotic count sheet showed several doses signed out by RN 1. A note indicated that the resident was unable to be interviewed but had not complained of pain, and all medications were accounted for. The facility's policy required immediate documentation of medication administration, which RN 1 failed to comply with, leading to her termination.
Failure to Follow Physician Orders and Communication Lapses
Penalty
Summary
The facility failed to adhere to physician's orders for multiple residents, leading to significant lapses in care. For Resident G, the facility did not follow orders to hold Humalog insulin when blood sugar levels were below 150, resulting in multiple instances of inappropriate administration. Additionally, the facility failed to administer clonidine as needed for elevated systolic blood pressure, despite clear physician instructions. Interviews with staff revealed a lack of adherence to these orders, contributing to the resident's chronic uncontrolled hypertension. Resident H experienced a delay in receiving treatment for a urinary tract infection due to poor communication between the facility and external healthcare providers. After an outpatient urology appointment, the facility did not receive or follow up on the necessary paperwork, resulting in a six-day delay in starting the prescribed antibiotic. Interviews indicated that the facility's standard practice of contacting providers within 24 hours was not followed, and there was no policy in place to ensure follow-up communication when residents returned without paperwork. For Resident F, the facility continued to administer medications that had been discontinued by hospice orders, including melatonin and lorazepam, while failing to start Seroquel as prescribed. This oversight persisted for several days, as hospice communication logs indicated the changes, but the facility did not update the orders in their system. Similarly, Resident 33 received metoprolol despite blood pressure readings that should have prompted the medication to be held. Lastly, Resident 105 did not have daily weights recorded as ordered, and Lasix was not administered according to weight gain parameters, with staff unable to provide reasons for these omissions.
Violation of Resident's Mail Privacy
Penalty
Summary
The facility failed to ensure that a resident's mail was delivered unopened, violating the resident's rights. During a resident council interview, a resident reported that her mail from Medicaid had been opened by the facility without her permission. The resident had explicitly indicated on a Permission & Acknowledgment form that she did not authorize facility personnel to open her mail, including Medicaid correspondence. Despite this, the Business Office Manager admitted to opening the resident's Medicaid approval letter and making a copy of her new Medicaid card before delivering it to her. This action was taken under the direction of the corporate office due to issues at other sister facilities where checks meant for the facility were delivered to residents. The facility lacked a specific policy regarding mail delivery or mail services, as confirmed by the Executive Director. The existing Resident Rights policy, dated 6/6/19, emphasized the resident's right to privacy and confidentiality, including communication by mail. The unauthorized opening of the resident's mail was a clear breach of this policy, as it violated the resident's right to privacy and confidentiality. The facility's actions were not aligned with the resident's expressed wishes and the facility's own policy on resident rights.
Inaccurate PASARR Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that pre-admission screening and resident reviews (PASARR) were accurate and updated for two residents. For Resident 87, the clinical record review revealed that the PASARR Level I, dated August 2, 2024, did not list any mental health medications, despite the resident being on Amitriptyline, an antidepressant, since admission. The Clinical Support nurse confirmed that the medication should have been included in the PASARR. Social Services 14 indicated that the social service department was responsible for ensuring PASARRs were up to date, and they should be updated when a resident receives a new mental health medication. For Resident D, the PASARR Level I, dated August 13, 2024, incorrectly indicated that the resident did not have a serious mental health disability, and no Level II screen was required. However, the resident was admitted with a diagnosis of bipolar disorder, which was also present on the admission Minimum Data Set (MDS) assessment. Social Services 14 acknowledged that the bipolar diagnosis was missed, and a Level II screening should have been initiated. The Clinical Support nurse noted that the facility did not have a policy for PASARR and followed the resident assessment instructions (RAI).
Failure to Include Insomnia in Resident's Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident diagnosed with insomnia. The resident, identified as Resident F, had multiple diagnoses including dementia, diastolic heart failure, and insomnia. Despite having physician's orders for melatonin, trazodone, and Seroquel to manage insomnia, these medications and the diagnosis were not included in the resident's care plan. Interviews with facility staff revealed that the social services department was responsible for ensuring diagnoses and medications were added to care plans, but this was not done for Resident F. Additionally, the facility lacked a specific policy for care plans and relied on the Resident Assessment Instrument (RAI) manual.
Resident Found with Vape in Room Against Facility Policy
Penalty
Summary
The facility failed to ensure that a resident did not have smoking articles in their room, which posed an accident hazard. During an observation, Resident 241 was found with an electronic cigarette (e-cigarette) or vape on his bedside table. When a CNA entered the room with the resident's lunch, the resident attempted to conceal the vape, but it remained visible. The CNA was unsure about the policy regarding vapes in residents' rooms. The resident's clinical record indicated diagnoses including opioid dependence, drug-induced constipation, unspecified pain, and anxiety disorder. Interviews with the Unit Manager and Executive Director confirmed that the facility was smoke-free and residents should not have vapes in their rooms. The facility's smoking policy stated that residents without independent smoking privileges may not keep smoking articles unless under direct supervision.
Failure to Administer Correct Oxygen Levels
Penalty
Summary
The facility failed to administer the correct amount of oxygen as ordered by the physician for two residents. Resident 10 was observed multiple times with their oxygen concentrator set at 3 liters per minute (L), despite a physician's order for 2L. This discrepancy was noted during observations on several dates, and interviews with staff confirmed the incorrect setting. The resident's medical history included heart failure, vascular dementia, type 2 diabetes, chronic pulmonary embolism, and respiratory failure, necessitating precise oxygen therapy management. Similarly, Resident 37 was observed receiving oxygen at 5L per minute, contrary to the physician's order of 2L. The Director of Nursing and a registered nurse confirmed the incorrect setting, emphasizing the responsibility of nursing staff to verify and maintain the correct oxygen flow rate. The facility's documentation on oxygen administration required verification of the physician's order prior to administering oxygen, which was not adhered to in these cases.
Failure to Adhere to Narcotic Count Procedures
Penalty
Summary
The facility failed to ensure proper narcotic count procedures were followed, as observed during a survey. Specifically, the narcotic log count sheets for the 700-unit and 400-unit were found to have numerous missing signatures from both on-coming and off-going staff. In the 700-unit, Book 1 was missing 31 signatures from off-going staff and 28 from on-coming staff, while Book 2 was missing 34 signatures from off-going staff and 33 from on-coming staff. Similarly, in the 400-unit, the narcotic log was missing 39 signatures from off-going staff and 30 from on-coming staff. These observations were made in the presence of Unit Manager 4 and LPN 19, who confirmed that staff were supposed to sign the narcotic log sheets at the beginning and end of each shift. The facility's current policy, titled 'Policy and Procedure for Scheduled Drugs' and dated March 2015, mandates that at the beginning and end of each shift, the outgoing and oncoming licensed nurse must count and account for all scheduled drugs together and complete the Nurse's Narcotic Sign In/Sign Out sheet. This policy was provided by the Corporate Support Nurse. The failure to adhere to this policy resulted in the observed deficiencies in narcotic count procedures, as confirmed by the interviews and record reviews conducted during the survey.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, dating, and storage of medications and supplements across three units, affecting two residents. On the 500-unit, an open Lantus insulin pen was found without a resident's name, and an anesthetic oral gel was improperly stored with ear drops. Additionally, a 30-ounce bottle of liquid protein was open and unlabeled. LPN 16 confirmed the insulin was expired and acknowledged the improper storage of the gel and ear drops. On the 800-unit, a 30-milliliter bottle of liquid protein was also found open and unlabeled, and a bottle of aplisol in the medication room refrigerator had a broken seal with no open date. Similarly, on the 700-unit, a bottle of aplisol was found with a broken seal and no open date, which Unit Manager 4 confirmed should have been dated upon opening. Resident 80 was observed with Diclofenac Sodium topical gel on his bedside table without a physician's order, and it remained there over consecutive days. Unit Manager 4 confirmed the resident should not have had the gel in his room. Resident 45 also had Diclofenac Sodium topical gel in his room with a label that did not appear to be from the facility's pharmacy. The facility's policies on drug storage and bedside medications were not adhered to, as expired medications were not removed, and unauthorized medications were found at residents' bedsides.
Failure to Provide Dental Services for Denture Repair
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services to repair or replace partial dentures. The resident, who had a history of repeated falls, bipolar disorder, oral phase dysphagia, Alzheimer's dementia with behavioral disturbance, anxiety, depression, and impaired memory, was observed on multiple occasions with missing front teeth. The resident's clinical record indicated that she had upper partial dentures upon admission, and a physician's order allowed for dentistry services as needed. However, after the resident's front teeth fell out in early July, there was no documentation of any dental visits or attempts to repair or replace the dentures. Interviews with facility staff, including the Assistant Director of Nursing, CNA, Unit Manager, and Administrator, revealed that there was confusion and lack of follow-up regarding the resident's dental care. The facility's policy required that residents with lost or damaged dentures be referred for dental services within three days, but there was no evidence that this was done. The Administrator admitted that there were no notes on dental consultations or visits, and the facility could not provide any further documentation on the status of the resident's partial dentures.
Failure to Serve Food at Safe and Appetizing Temperature
Penalty
Summary
The facility failed to ensure that food was served at a safe and appetizing temperature for residents receiving room trays. Multiple residents, including Residents E, D, B, and C, reported that their food was cold, with Resident C also noting that the food lacked good flavor. During a resident council meeting, it was indicated that room trays were sometimes cold. An observation on 10/31/24 revealed that a lunch tray had food items, such as country fried steak, peas, and glazed carrots, served at temperatures below the facility's standard of at least 120 degrees. The Assistant Dining Services Supervisor acknowledged that the food should be reheated to meet the required temperature. The facility's policy mandates that hot food not served at a preferable temperature should be reheated to an internal temperature of 165 F for 15 seconds or replaced.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in five rooms, as observed during a survey. In one room, brown stains were noted on six ceiling tiles, and a telephone outlet was missing a cover, exposing wires. The unit manager was unaware of the reason for the missing cover. Another room had a large brown stain on the ceiling and a constantly dripping kitchenette sink faucet. Additionally, a room was found with an improperly fitted light switch cover, leaving a visible hole between the cover and the wall. In another instance, a resident's room had food drip stains on the wall and window, with dried debris stuck to the window and a cracked windowsill with a milky white substance. These conditions remained unchanged over several days. Furthermore, a room was observed with opened wound supplies left on a table, which the unit manager acknowledged should have been discarded. During an environmental tour, the maintenance supervisor and administrator were unaware of some of these issues, such as the brown stains on the ceiling and the missing telephone outlet cover. The facility's job description for the Environmental Services Supervisor outlines responsibilities for maintaining a clean and safe environment, which were not met in these instances.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined a resident was clinically appropriate to self-administer medications. During a random observation, a Licensed Practical Nurse (LPN) was found to have left a resident alone in their room with medication cups and a nebulizer vial within reach. The resident's clinical record did not contain an assessment for self-administration of medication, a physician's order, or a care plan for self-administration. The resident was cognitively intact according to a Brief Interview for Mental Status (BIMS) assessment conducted a few months prior, but no formal assessment for self-administration had been documented. The facility's policy on bedside medications and self-administration requires that the interdisciplinary team determine the safety of self-administration for each resident. However, this protocol was not followed for the resident in question. The LPN admitted to stepping out of the room to assist another resident, leaving the medications unattended. This oversight indicates a failure to adhere to the facility's own policies and procedures regarding medication administration and resident safety.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for one of the residents reviewed. During a medication pass observation, an LPN used her fingers to remove an Acidophilus/Pectin capsule from the medication bottle and placed it in a medication cup for administration to a resident. The resident's clinical record indicated diagnoses including vascular dementia, chronic kidney disease, and insomnia, with a physician's order for the probiotic. The LPN acknowledged that she should not have used her fingers and mentioned having a spoon available for such tasks. The facility's procedure explicitly stated that tablets and capsules should be handled without touching them with fingers.
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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