Cedar Creek Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Lowell, Indiana.
- Location
- 18275 Burr Street, Lowell, Indiana 46356
- CMS Provider Number
- 155822
- Inspections on file
- 25
- Latest survey
- June 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cedar Creek Health Campus during CMS and state inspections, most recent first.
Two residents with cognitive impairments and dietary orders for therapeutic or fortified diets did not consistently receive meals as prescribed by their physicians. Observations revealed that required fortified foods and specific meal components were omitted, despite care plans and dietary cards indicating these needs. The dietary manager confirmed that the appropriate fortified foods were not always provided.
A resident reported missing personal clothing items, but the facility failed to document or investigate the grievance as required by policy. Staff were aware of the missing items, yet no grievance form was completed and no follow-up was recorded in the grievance system.
A resident with multiple chronic conditions received propranolol and hydrochlorothiazide outside of the physician-ordered blood pressure and heart rate parameters on several occasions. The DON confirmed that these medications should have been held per the orders.
Two residents at risk for falls did not receive required safety interventions: one used a wheelchair with a broken brake that had not been repaired despite staff awareness, leading to a fall, and another did not have a care plan-required bathroom sign to remind her to call for assistance, with staff noting she often removed such signs.
A resident with an indwelling Foley catheter was observed with the catheter collection bag on the floor, and staff failed to document urinary output in milliliters as required, instead using qualitative terms such as 'small,' 'medium,' or 'large.' The DON confirmed there was no specific facility policy for documenting urinary output for catheterized residents.
A resident with acute respiratory failure and hypoxia was observed twice receiving oxygen at 2 LPM, despite a physician's order for continuous administration at 4 LPM by nasal cannula. An LPN confirmed the error and adjusted the flow rate to the correct setting after it was identified.
A resident with multiple chronic conditions received acetaminophen for pain on numerous occasions without documentation of pain location, severity, or use of non-pharmacological interventions prior to administration. The care plan required these steps, but medication records did not reflect them, and the DON confirmed that such documentation should have occurred.
A resident with severe cognitive impairment and a feeding tube, who was under physician-ordered Enhanced Barrier Precautions, did not have required signage or PPE bins present in their room. Staff did not visibly implement the necessary infection control measures during surveyor observations.
The facility failed to serve breakfast within 14 hours of dinner for residents in the VIP Dining Room, with breakfast being served at 10:06 a.m. due to delays in getting residents seated. Dinner was served the previous evening between 4:45 p.m. and 5:15 p.m., resulting in a gap exceeding 14 hours. The delay was attributed to CNAs' inability to get residents to the dining room on time and dietary staff waiting to serve meals until most residents were seated.
A resident with dementia frequently refused bathing, yet the facility failed to document these refusals or update the care plan to reflect this behavior. The resident had not been bathed since admission, and the DON and Social Service Director were unaware of the issue due to inadequate communication and documentation. The facility's policy for behavior assessment and intervention was not followed, leading to a deficiency in care.
A cognitively impaired resident with a history of exit-seeking behavior eloped from a facility due to inadequate supervision and a malfunctioning door alarm. The resident exited through an alarmed door that was left open by a rug, and the Wanderguard alarm was not heard by staff due to improper wiring. The resident was found 0.3 miles away and returned without injury after being assessed by EMS.
The facility failed to provide necessary ADL care for two residents. One resident had long, thickened, and discolored fingernails despite expressing a desire to have them trimmed. Another resident had grown-out facial hair and disheveled hair, with no documentation of assistance with shaving. The DON acknowledged the deficiencies and cited issues with equipment and communication.
The facility failed to monitor and assess skin discolorations for three residents, including one with atrial fibrillation and hypertension, another with dementia and pulmonary fibrosis, and a third with dementia and Parkinson's disease. Despite care plans and progress notes indicating the need for monitoring, there was a lack of follow-up and documentation on their skin conditions.
A facility failed to ensure a resident received necessary treatment to prevent a decrease in range of motion due to improperly positioned leg rests and a footboard on a wheelchair. The resident, with diagnoses including dementia and a history of falls, repeatedly attempted to place her feet on the floor but was repositioned by an Activity Aide. The DON and TD later confirmed the leg rests were not positioned correctly, leading to incidents where the resident almost tipped her chair and turned her wheelchair over.
A facility failed to ensure a g-tube was properly checked for placement before medication administration for a resident. An LPN used an air bolus instead of removing residual from the g-tube, contrary to facility policy. The LPN acknowledged the mistake, and the Director of Nursing had no further information.
The facility failed to ensure proper medication storage, with unidentified and crushed pills found in two medication carts. Night shift staff were responsible for cleaning the carts, but this was not done. The DON was informed but had no further information.
Failure to Serve Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to ensure that therapeutic diets were served as ordered by the physician for two of three residents reviewed. For one resident with vascular dementia and a severely impaired cognitive status, observations showed that breakfast and lunch meals did not consistently match the physician's order for a regular diet with fortified foods, as indicated on the meal card and care plan. The care plan specifically noted the resident was at risk for malnutrition and required the diet to be served as ordered by the physician. Another resident, diagnosed with dementia and stroke and assessed as requiring a mechanically altered and therapeutic diet, was observed receiving meals that did not align with the physician's order for a no added salt, mechanical soft diet with fortified foods. The resident's breakfast and lunch did not include the required fortified foods, and the lunch meal was missing a specified side dish. The dietary manager confirmed that fortified foods, such as yogurt or oatmeal, should have been provided but were not consistently served.
Failure to Document and Investigate Resident Grievance Regarding Missing Clothing
Penalty
Summary
A resident who was cognitively intact and required substantial assistance for bed mobility and transfers reported missing personal clothing items, specifically a baseball sweatshirt and a blue and white nightgown. The resident stated that the sweatshirt had been missing for a couple of months and the nightgown for approximately two weeks, and neither item had been found or replaced. Despite these concerns, a review of the facility's grievance records for the past six months revealed no documentation of grievances from this resident regarding the missing clothing. Interviews with facility staff confirmed awareness of the missing items, with the DON acknowledging knowledge of the situation but being unable to specify when the sweatshirt was ordered or if a grievance had been filed. The Executive Director also confirmed that the resident had reported the missing items but that no grievance form had been completed. The facility's policy requires that concerns be documented and followed up within 24-48 hours, but this process was not followed in this case.
Failure to Hold Medications per Blood Pressure and Heart Rate Parameters
Penalty
Summary
The facility failed to ensure that medications were administered or withheld according to physician orders and specified blood pressure and heart rate parameters for a resident with multiple diagnoses, including Parkinson's disease, chronic kidney disease, and congestive heart failure. The resident was assessed as moderately cognitively impaired and had physician orders for propranolol to be held if the heart rate was less than 60 beats per minute or systolic blood pressure was less than 120, and for hydrochlorothiazide to be held if systolic blood pressure was less than 120. Despite these orders, documentation showed that propranolol was administered on several occasions when the resident's blood pressure and/or heart rate were below the specified thresholds. Similarly, hydrochlorothiazide was given when the resident's systolic blood pressure was below the ordered parameter. The Director of Nursing confirmed in an interview that the medications should have been held according to the physician's orders.
Failure to Implement Fall Prevention Measures and Maintain Equipment Safety
Penalty
Summary
The facility failed to implement adequate safety measures for two residents at risk for falls. One resident, who was cognitively intact and required substantial assistance for mobility and transfers, reported falling in the bathroom due to an unstable wheelchair with a broken right brake. The resident stated she had informed several staff members about the malfunction, and observation confirmed the brake was not working. Staff interviews revealed awareness of the issue, but a work order for repair was not placed until after the incident, and facility leadership was not aware of the problem until then. Another resident, also cognitively intact and with a history of multiple fractures and falls, did not have a required sign in her bathroom reminding her to call for assistance, as specified in her care plan. Observations confirmed the absence of the sign on two occasions. The resident's care plan included this intervention due to her high fall risk, but staff indicated the resident frequently removed such signs, believing she did not need help. The facility's fall management policy requires investigation and intervention after falls, but the specified interventions were not consistently implemented.
Failure to Maintain Proper Catheter Bag Position and Accurate Output Documentation
Penalty
Summary
A deficiency was identified when a resident with a history of neuromuscular dysfunction of the bladder, urinary retention, and previous urinary tract infections was observed with an indwelling Foley catheter collection bag resting on the floor under her wheelchair on two separate occasions. The resident was noted to be severely cognitively impaired and had physician orders for an indwelling urinary catheter with catheter care to be performed every shift. The care plan included interventions such as maintaining the catheter bag below the bladder, keeping the leg strap in place, and recording urinary output. Upon review of the resident's records, it was found that documentation of urinary output was not completed as required. Instead of recording the actual volume in milliliters, staff documented output as 'small,' 'medium,' or 'large' on multiple occasions over a two-month period. During an interview, the DON confirmed that the facility did not have a specific policy regarding documentation of urinary output for residents with catheters and had no further information to provide.
Failure to Provide Prescribed Oxygen Flow Rate
Penalty
Summary
A resident with diagnoses including acute respiratory failure with hypoxia and metabolic encephalopathy was observed using portable oxygen in her room, with the flow meter set at 2 liters per minute (LPM). According to the resident's physician order, oxygen was to be administered continuously at 4 LPM by nasal cannula. The resident, who was moderately cognitively impaired and dependent on staff for toileting and transfers, was observed twice with the oxygen set incorrectly at 2 LPM. During the second observation, an LPN acknowledged the error and adjusted the flow rate to the prescribed 4 LPM at that time. This deficiency occurred because the facility failed to ensure the resident received the necessary care and treatment related to the prescribed oxygen flow rate.
Failure to Document Pain Assessment and Non-Pharmacological Interventions Before Administering Pain Medication
Penalty
Summary
The facility failed to ensure that a resident’s pain medication regimen was free from unnecessary drugs by not documenting pain assessments or the use of non-pharmacological interventions prior to administering acetaminophen. A resident with diagnoses including chronic bronchitis, heart failure, anemia, and atrial fibrillation, who required substantial assistance for mobility, received acetaminophen 15 times over an 18-day period. The medication administration records lacked documentation of pain location, severity, or any non-pharmacological interventions attempted before giving the medication, despite the care plan specifying these interventions and documentation. The DON confirmed that pain level, site, and prior interventions should have been documented before administering the pain medication.
Failure to Implement Enhanced Barrier Precautions for Resident on Isolation
Penalty
Summary
The facility failed to implement infection control guidelines for Enhanced Barrier Precautions for a resident who required isolation. Observations on two separate occasions revealed that there were no signs posted on or near the resident's door to indicate Enhanced Barrier Precautions were in place, and there were no personal protective equipment (PPE) bins available near or inside the room. The resident's medical record showed diagnoses including dysphagia and dementia, with documentation indicating severe cognitive impairment and the need for a feeding tube. A physician's order specified that staff should use a gown and gloves during high-contact care activities for this resident, but these precautions were not visibly supported in the environment at the time of surveyor observation.
Delayed Breakfast Service in VIP Dining Room
Penalty
Summary
The facility failed to ensure that meals were served with no more than 14 hours between the evening meal and breakfast the following day, affecting residents in the VIP Dining Room. On the morning of January 21, 2025, breakfast was observed being served to 11 residents in the VIP Dining Room at 10:06 a.m., which was significantly later than the expected time of 8:30 a.m. to 9:00 a.m. The delay was attributed to the CNAs being unable to get all residents to the dining room on time, and the dietary staff waiting until most residents were seated to keep the food warm. The previous evening, dinner was served in the VIP Dining Room between 4:45 p.m. and 5:15 p.m., depending on when the kitchen staff received a call from the CNAs indicating residents were ready to eat. This resulted in more than 14 hours between dinner and breakfast for the residents in the VIP Dining Room. The Director of Food Services and the Director of Nursing were both aware of the situation, with the latter noting that CNAs were already preparing residents for the day when she left the facility early in the morning.
Failure to Address Bathing Refusals in Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident with dementia, who frequently refused bathing, received the necessary bathing services at least twice a week. The resident, who had a preference for showers, indicated she had not been bathed since her admission. The care plan required assistance for activities of daily living (ADLs) and included interventions such as not rushing the resident and offering encouragement. However, the plan did not reflect the resident's behavior of refusing baths. The facility's documentation showed multiple instances of the resident refusing showers, but these refusals were not documented in the progress notes or behavior point of care documentation. The Director of Nursing (DON) and Social Service Director were unaware of the resident's consistent refusals, as the refusals were not communicated or documented properly. The facility's policy required behaviors to be assessed and evaluated, with interventions communicated to the interdisciplinary team, but this process was not followed. The DON conducted random audits but did not identify the issue due to the lack of documentation. The facility's failure to document and address the resident's bathing refusals led to a deficiency in providing appropriate care for the resident's dementia-related behaviors.
Resident Elopement Due to Inadequate Supervision and Alarm Malfunction
Penalty
Summary
The facility failed to provide adequate supervision to a cognitively impaired resident with a history of exit-seeking behavior, resulting in the resident eloping from the facility. The resident, who was wearing a Wanderguard bracelet, managed to exit through an alarmed door that was left open due to a rug obstructing it. The resident was found 0.3 miles away by a Good Samaritan, who called 911. The resident was returned to the facility without injury after being assessed by EMS. The incident occurred when the resident, who had been administered Xanax for anxiety, was left unsupervised between 6:15 p.m. and 6:47 p.m. on the day of the elopement. Staff statements indicated that the resident had been exhibiting exit-seeking behavior earlier in the day, and interventions such as walking with the resident or offering a snack were not documented as being implemented. The door alarm, which should have been triggered by the Wanderguard, was not heard by staff, and the annunciator panel was found to be improperly wired, preventing the alarm from being heard in the Assisted Living Nurses' Station. Interviews with staff revealed a lack of awareness and response to the door alarm. Environmental Services staff adjusted the rug and closed the door without recalling if the alarm was sounding. The facility's policy required prompt response to door alarms, but staff did not follow the procedure to ensure the resident's safety. The facility's failure to ensure the door alarm system was fully functional and to provide adequate supervision contributed to the resident's elopement.
Removal Plan
- The rug in the vestibule was removed.
- All residents in the facility were reviewed for elopement risk.
- The residents who were assessed as an elopement risk have Wanderguard bracelets initiated.
- All Physician's Orders for the bracelets and checking for functioning and placement were reviewed and were up to date.
- All exit doors have been evaluated to ensure the Wanderguard is functioning.
- Elopement binders have been updated.
- 93 of 122 employees have been educated on the elopement/missing resident policy and all remaining staff will be educated upon their return to work.
- An elopement drill was completed without concerns.
Failure to Provide Necessary ADL Care
Penalty
Summary
The facility failed to ensure residents received the necessary care for activities of daily living (ADL) related to long unkempt fingernails and the lack of offering residents shaving per the plan of care. Resident 21 was observed on multiple occasions with long, thickened, and discolored fingernails. Despite the resident expressing a desire to have her nails trimmed, no one had offered to trim them. The resident's care plan indicated she required substantial assistance with personal hygiene due to her medical conditions, including diabetes mellitus, dementia, stroke, and Parkinson's disease. The Director of Nursing (DON) acknowledged that the staff should have attempted to soak and cut her fingernails before the surveyor's observation. Resident 26 was observed with grown-out facial hair and disheveled hair on multiple occasions. His care plan indicated he required staff assistance to complete ADL tasks, including offering facial shaving on shower days or as needed. However, there was no documentation available in the record related to the resident receiving assistance with shaving. The DON indicated that the resident's electric razor had broken, and they were trying to get it replaced but were unable to contact the resident's son. The DON also mentioned that shaving was considered basic care and did not need to be documented in the record.
Failure to Monitor and Assess Skin Discolorations
Penalty
Summary
The facility failed to ensure residents received the necessary treatment and services related to the monitoring and assessment of skin discolorations for three residents. Resident 38, who had diagnoses including atrial fibrillation and hypertension, was observed with dark purple discolorations on her hands and multiple bandaids over several days. Despite being at risk for excessive bleeding and bruising due to her medications, there was a lack of follow-up on her skin discolorations after an initial event note indicated various stages of healing. Weekly skin assessments did not document any new skin issues, and the Director of Nursing (DON) acknowledged the need to start a skin event for the resident. Resident 4, diagnosed with dementia and pulmonary fibrosis, was observed with a large scabbed area on his right knee. After a fall, a progress note indicated his right knee was red but blanchable, with no further documentation or monitoring of the scabbed area. Weekly skin assessments failed to indicate any new skin issues, and the DON confirmed the lack of further monitoring after the initial fall. Resident 26, with diagnoses including dementia and Parkinson's disease, was observed with discolorations and a small abrasion on his left forearm. Despite a care plan indicating the need for weekly skin assessments and observation during routine caregiving, there was no documentation related to the abrasion and discoloration. The DON mentioned that the resident self-propelled throughout the facility, which likely caused the old abrasion, but could not provide additional information.
Failure to Ensure Proper Wheelchair Positioning for Resident
Penalty
Summary
The facility failed to ensure a resident received the necessary treatment to prevent a decrease in range of motion related to improperly positioned leg rests and a footboard on a wheelchair. Resident 154, who has diagnoses including dementia, anxiety, and a history of falls, was observed in a wheelchair with leg rests and a footboard extended horizontally. The resident repeatedly attempted to place her feet on the floor, but an Activity Aide continually repositioned her feet back onto the leg rests, indicating the resident was at risk of falling if she tried to stand. The Director of Nursing (DON) was unaware of the reason for the leg rests being positioned that way and later found that the resident tried to stand when the leg rests were removed, indicating the leg rests should not have been positioned so high since the resident could propel herself in the wheelchair. The Therapy Director (TD) confirmed that the leg rests and footboard were recommended for positioning and safety but should not have been positioned horizontally. The TD was unaware of recent incidents where the resident almost tipped her chair and turned her wheelchair over in the dining room, indicating a lack of proper documentation on the assistive devices recommended by therapy staff.
Improper G-Tube Placement Check Before Medication Administration
Penalty
Summary
The facility failed to ensure a gastrostomy tube (g-tube) was properly checked for placement prior to medication administration for one resident. During a medication pass observation, an LPN was seen preparing and administering medications to the resident with a g-tube. The LPN checked the g-tube placement using an air bolus instead of removing residual from the g-tube as per the facility's policy. The LPN then proceeded to administer the medications and flushes through the g-tube without following the correct procedure for checking tube placement. During an interview, the LPN acknowledged that the correct procedure was to check for placement by removing residual from the g-tube, not with an air bolus. The Director of Nursing had no further information to provide. The facility's policy indicated that proper tube placement should be checked using air and auscultation only, and that gastric content should be checked for residual feeding, with any residual volumes above 100 ml to be reported.
Improper Medication Storage in Medication Carts
Penalty
Summary
The facility failed to ensure medications were stored appropriately, as evidenced by unidentified and crushed pills found in medication cart drawers for two medication carts. The 100 Hall Medication Cart was observed with multiple unidentified whole pills and crushed medications in the drawer. RN 1 indicated that the night shift staff was responsible for cleaning the medication carts, but this was not done. Similarly, the 300 Hall Medication Cart was found with two unknown whole pills in the drawer. RN 2 also stated that the night shift staff was supposed to clean the carts. The Director of Nursing was informed of the findings but had no further information to provide. The facility's policy on medication storage requires that all medications be stored in labeled containers and that outdated or contaminated medications be immediately removed and disposed of properly.
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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