Cobblestone Crossings Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Terre Haute, Indiana.
- Location
- 1850 E Howard Wayne Dr, Terre Haute, Indiana 47802
- CMS Provider Number
- 155772
- Inspections on file
- 29
- Latest survey
- October 23, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Cobblestone Crossings Health Campus during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was physically and mentally abused when a CNA rushed and roughly handled her during a transfer, despite care plans requiring two-person assistance and unhurried care. The CNA pulled and yanked the resident's arm, failed to communicate the procedure, and ignored requests from other staff to stop, resulting in the resident's distress.
A resident with severe cognitive impairment and total incontinence, who required maximum assistance for transfers, was reportedly rushed during care by a CNA. An LPN observed the incident but did not document it or complete required assessments, and the event was not reported to the Administrator in a timely manner, contrary to facility policy.
A resident with multiple complex conditions, including liver disease, dementia, and severe malnutrition, experienced significant weight gain and worsening edema during her stay. Despite repeated concerns from family about swelling and abdominal distension, staff attributed changes to improved nutrition and inconsistently documented edema. Compression stockings caused further harm, and the resident was ultimately transferred to the hospital, where large volumes of fluid were drained. The facility failed to thoroughly assess and address the resident's symptoms, resulting in a deficiency in quality of care.
A resident with significant edema and cognitive impairment sustained a superficial laceration to her lower extremity when an LPN used bandage scissors to remove a tight dressing, resulting in a cut that later became infected and required antibiotic treatment. The incident occurred after a family member requested the dressing be removed due to tightness, and the LPN acknowledged that unwrapping the dressing would have been safer given the resident's condition.
The facility failed to properly label and store medications on two medication carts. An opened Lantus insulin pen was undated, and several unopened medications, including insulin pens and eye drops, were not refrigerated as required. The RN attributed the oversight to a new night shift nurse unaware of proper procedures. Residents involved had conditions like type 2 diabetes and glaucoma, necessitating these medications.
A resident with respiratory issues was found with medications at her bedside without a completed self-administration assessment or authorization. Despite having physician's orders for medication administration, there was no order for self-administration. Facility staff confirmed that no residents were authorized to self-administer medications, and the medications matched those from the facility's cart, not brought from home. The facility's policy requiring an assessment and order for self-administration was not followed.
The facility failed to accurately document the code status for two residents, leading to discrepancies in their medical records. One resident's records showed conflicting DNR and full code statuses, while another resident's records had both DNR and CPR consent forms signed on the same date. These inconsistencies created confusion regarding the residents' advanced directives, highlighting a failure to adhere to the facility's policy on documenting end-of-life care wishes.
A facility failed to conduct quarterly care plan meetings for a resident with a bimalleolar fracture and type 2 diabetes. The resident could not recall recent meetings, and records showed no meetings since November 2023. Interviews confirmed the facility was behind on care plan meetings, lacking documentation for the resident's meetings.
A resident with a history of osteoporosis, DVT, and chronic kidney disease was observed with edema in her left foot and ankle, but the facility failed to notify a physician or maintain a care plan for this condition. Despite previous observations of swelling, there was no recent assessment or monitoring of the edema or DVT, as confirmed by staff interviews. The facility's policy to identify and monitor clinically at-risk residents was not followed in this case.
A resident's urinary catheter and biliary drain bags were repeatedly found on the floor without coverings, contrary to facility policy. The resident, with a complex medical history, required specific care interventions that were not followed, as confirmed by staff interviews. The facility's guidelines mandate that drainage bags be covered and not touch the floor, which was not adhered to in this case.
A facility failed to properly clean and store respiratory equipment for a resident, including nasal cannula and CPAP mask and tubing. Observations showed undated oxygen tubing and lack of a dated storage bag. Staff interviews confirmed non-compliance with facility policy, which required proper storage and dating of equipment. The resident had a history of respiratory issues, necessitating continuous oxygen therapy and CPAP use, but the facility did not follow the prescribed protocols.
The facility failed to maintain food safety and sanitation standards during a kitchen observation. Raw hamburger meat was improperly stored on a cart with prepared salads outside of the cooler, and an employee was observed without a beard covering in the kitchen. The Director of Food Services admitted to removing the meat from the cooler and placing it on the cart, but could not recall how long it had been out. Facility policies require proper storage of potentially hazardous foods and beard coverings in food production areas.
A facility failed to properly handle and sanitize a glucometer during medication administration for two residents with type 2 diabetes. A nurse used the glucometer without placing a barrier under it and did not sanitize it between uses, contrary to facility policy. This was confirmed by an LPN, who noted the glucometer was used for multiple residents and should be cleaned between uses.
A resident with chronic kidney disease and obstructive uropathy missed a urology appointment due to the facility's failure to arrange transportation. Despite a physician's order, the transport was not scheduled, partly due to a time-consuming process and lack of a specific policy. The Life Enrichment Director and nursing staff were involved, but the resident was not on the transport schedule.
A CRCA left a resident with dementia unattended during personal care due to frustration with the resident's combative behavior. The resident, who had a history of aggressive behavior, was later attended to by an RN and another CRCA. The facility's policy on resident rights, which emphasizes dignity and respect, was not followed.
Failure to Prevent Physical and Mental Abuse During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing aide (CNA) physically and mentally abused a resident with severe cognitive impairment during a transfer. The resident, who had Alzheimer's disease, depression, and was dependent on staff for all activities of daily living, was observed being rushed and handled roughly by the CNA. The CNA was seen pulling and yanking the resident's arm while attempting to transfer her from a chair to bed, without first explaining the procedure or ensuring the resident was ready. The resident became visibly upset, resisted the transfer, and displayed signs of distress, such as laughing angrily and gritting her teeth. Multiple staff members witnessed the incident. One CNA entered the room and observed the resident being pulled and yanked by the arm, and heard the CNA repeatedly and loudly urging the resident to get up. Despite being asked to leave the room by another CNA and an LPN, the CNA continued to attempt the transfer and only left after repeated requests. The resident was calmed by another CNA after the incident, and no physical injuries were noted, but the resident was clearly distressed by the interaction. The facility's care plans for the resident specified that she required maximum assistance from two staff members for transfers and that staff should allow her sufficient time to complete tasks without rushing. The CNA failed to follow these care plan interventions, instead rushing the resident and using rough handling during the transfer. The incident was reported by staff, and interviews confirmed that the CNA's approach was inappropriate and did not align with the resident's care needs or the facility's abuse prevention policies.
Failure to Timely Report Suspected Abuse Incident
Penalty
Summary
The facility failed to report an incident of potential resident abuse by a staff member in a timely manner to the Administrator. A Certified Nursing Aide (CNA) was reported by another CNA for rushing a resident during care. The incident involved a resident with severe cognitive impairment, Alzheimer's disease, depression, and total urinary and bowel incontinence, who was dependent on staff for all activities of daily living. The resident required maximum assistance for transfers and was at risk for skin breakdown. The care plan specifically indicated that staff should not rush the resident and should allow sufficient time for tasks. The incident was observed by an LPN, who saw the CNA pulling on the resident's arm during a transfer. Although a head-to-toe assessment was reportedly performed, the LPN failed to document the incident or the assessment in the clinical record, and did not take vital signs or complete a pain assessment following the event. The facility's policy required immediate reporting of suspected abuse to the Executive Director, but this was not done in a timely manner. The deficiency was identified through record review and staff interviews.
Failure to Assess and Address Edema and Weight Gain in Resident with Complex Medical Needs
Penalty
Summary
The facility failed to complete thorough assessments and provide appropriate care for a resident with significant medical conditions, including liver disease, dementia, acute kidney failure, ascites, localized edema, and severe protein-calorie malnutrition. The resident experienced a substantial weight gain over the course of her stay, with her weight increasing from 85.4 lbs at admission to 106 lbs at discharge. Despite this significant change, the facility attributed the weight gain to improved nutrition and did not adequately investigate or address the possibility of fluid retention, even though the resident had a history of ascites and generalized edema (anasarca). Family members repeatedly raised concerns to staff about the resident's increasing abdominal size and swelling in her lower legs, but these concerns were dismissed or minimized by both staff and the facility physician. Compression stockings were applied to the resident, resulting in hematomas and significant discomfort, leading the family to refuse further use. The facility's documentation of the resident's edema was inconsistent, with some assessments noting its presence and others, including one on the day of transfer to the emergency department, indicating its absence. However, emergency department records from the same day documented 2 to 3 plus pitting edema in the resident's lower extremities, as well as a blood blister and cold extremities. The resident's condition deteriorated to the point that her primary care physician arranged for her transfer to the emergency department, where she was found to have significant fluid accumulation and subsequently had three liters of fluid drained from her abdomen at an acute care hospital. Interviews with facility staff revealed a lack of awareness regarding the resident's abdominal swelling and weight gain, and the facility lacked a specific policy addressing the management of such changes in condition. The failure to conduct thorough assessments and respond appropriately to the resident's symptoms and family concerns led to a deficiency in the quality of care provided.
Resident Laceration During Dressing Removal
Penalty
Summary
A deficiency occurred when a resident sustained a laceration to her left lower extremity during a dressing removal performed by an LPN. The incident took place after the resident's family member requested the removal of a dressing on the resident's left knee, citing concerns that it was too tight. The LPN, who was in the middle of a medication pass, paused her duties to address the request. She used bandage scissors to cut through the gauze dressing, inserting the dull end under the dressing. During the process, the resident moaned, and upon removal of the gauze, a superficial cut approximately eight centimeters long was discovered on the resident's skin, with scant bleeding present. The resident had a medical history significant for liver disease, dementia, ascites, and edema, and was severely cognitively impaired and dependent on staff for most activities of daily living. The dressing that was removed had been in place for several days and was covering a pre-existing V-shaped skin tear. The LPN attributed the injury to the tightness of the dressing and the presence of edema, which made the skin puffy and more susceptible to injury. The LPN acknowledged that unwrapping the dressing, rather than cutting it, would have been a safer approach given the resident's condition. Following the incident, the laceration became infected, requiring treatment with an oral antibiotic and topical bacitracin. The facility's policy on wound and skin care emphasized the need for care when removing all dressings and tapes. The family member present at the time expressed concern about the nurse's competence and the additional harm caused to the resident, who had to recover from both the original wound and the new laceration.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications for two medication carts reviewed. On the 200 hall (front) medication cart, an undated and opened Lantus insulin pen was found, which was labeled for a resident with type 2 diabetes mellitus. The Registered Nurse (RN) acknowledged that insulin pens should have an open date when used. Additionally, the 200 hall (back) medication cart contained several unopened and non-refrigerated medications, including Basaglar and Lantus insulin pens, a vial of Humalog, and a bottle of Latanoprost eye drops, all of which were labeled for specific residents or facility stock. The RN indicated that these medications should have been refrigerated until used, and attributed the oversight to a new nurse on the night shift who was unaware of the proper storage procedures. The residents involved had various medical conditions, including type 2 diabetes, diabetic chronic kidney disease, and glaucoma, which required the administration of these medications. The facility's policies, as provided by the Regional Director of Clinical Services, indicated that insulin pens and certain other medications should be stored in the refrigerator until used, and that the date opened should be recorded on vials and ampules of injectable medications. The failure to adhere to these policies resulted in the improper storage and labeling of medications, as observed during the survey.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a medication self-administration assessment was completed for a resident with respiratory issues, identified as Resident 11. During an initial interview, it was observed that the resident had an inhaler, Trelegy Ellipta, on her bedside table, which she claimed was hers and used regularly. Additionally, during a random observation, two vials of nebulizer solution were found on the resident's bedside table. The resident mentioned that she usually set up the nebulizer herself but was currently unable to do so due to a wrist brace. Despite the presence of these medications, there was no documentation or assessment indicating that the resident was authorized to self-administer her medications. The resident's medical records revealed diagnoses including bipolar II, schizoaffective disorder, and chronic obstructive pulmonary disease (COPD). Physician's orders were in place for the administration of Trelegy Ellipta, ipratropium-albuterol solution, and albuterol sulfate inhaler, but there was no order for self-administration. The care plan noted the potential for complications related to respiratory disease, and a recent assessment indicated the resident was cognitively intact. However, interviews with facility staff, including an LPN and the Director of Health Services, confirmed that no residents, including Resident 11, had orders to self-administer medications. Further investigation revealed that the medications found at the resident's bedside matched those from the facility's medication cart, indicating they were not brought from home. The facility's policy required an assessment and physician's order for self-administration, which was not present in this case. The policy also stated that medications should not be left at the bedside unless specifically ordered by a prescriber, which was not adhered to, leading to the deficiency.
Discrepancies in Code Status Documentation for Two Residents
Penalty
Summary
The facility failed to accurately document the code status of two residents, leading to discrepancies in their medical records. For Resident 34, the face sheet and a physician's order indicated a Do Not Resuscitate (DNR) status, while the most recent Physician Order for Scope and Treatment (POST) form indicated a full code status, which meant resuscitation should be attempted. This inconsistency was noted during a review of the resident's record, and the Licensed Practical Nurse (LPN) confirmed the discrepancy upon checking the documents. The Regional Director of Clinical Services (RDCS) acknowledged the issue and mentioned contacting hospice and the resident's wife for verification. For Resident 196, the medical record indicated a DNR status, but a CPR consent form signed by the resident on the same date suggested CPR should be initiated. This conflicting information created confusion regarding the resident's advanced directives. The Director of Health Services (DHS) recognized the discrepancy and acknowledged the confusion it caused. The resident's medical record also lacked a care plan for advanced directives, further complicating the situation. The facility's policy on advanced directives, provided by the Regional Nurse Consultant, outlined procedures for obtaining and following residents' end-of-life care wishes. However, the discrepancies in the documentation of code status for both residents indicate a failure to adhere to these procedures, resulting in unclear and conflicting directives in the residents' medical records.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were held at least quarterly for a resident, identified as Resident 8, who was reviewed for care plan meetings. During an interview, the resident indicated that she could not recall having a care plan meeting for quite some time. A review of the resident's records showed that she had been admitted to the facility with diagnoses including a displaced bimalleolar fracture of the right lower leg and type 2 diabetes. The quarterly Minimum Data Set (MDS) assessment indicated that the resident had no cognitive deficit. However, the review of the Resident First Meeting Minutes lacked documentation of a care plan meeting since November 1, 2023. Interviews with the Resident Services Manager and the Regional Director of Clinical Services confirmed that the facility was behind in completing care plan meetings, and they were unable to locate any documentation indicating that a care plan meeting had been held for the resident since November 2023. The facility's policy, provided by the Regional Director of Clinical Services, stated that meetings for non-Medicare residents should be conducted at a minimum of quarterly and with significant change, while meetings for Medicare residents should be conducted minimally quarterly and prior to discontinuing Medicare services or being discharged from the facility.
Failure to Monitor and Notify Physician of Resident's Edema
Penalty
Summary
The facility failed to assess and ensure that a physician was notified of a resident's change in condition related to edema. Resident 7, who has a history of age-related osteoporosis, a previous DVT in the left leg, and chronic kidney disease stage 3b, was observed multiple times with edema in her left foot and ankle. Despite these observations, the resident's record lacked a care plan specifically addressing the edema, and there were no recent progress notes related to the condition. The resident had been prescribed Xarelto following a previous DVT diagnosis, but there was no evidence of continued monitoring of the edema or DVT by the staff. Interviews with facility staff revealed that the edema had been noticed previously, but there was no recent assessment or notification to the physician regarding the current state of the edema. The Regional Director of Clinical Services acknowledged that the edema should have been addressed with the physician and that a clinical assessment record should have been completed to ensure proper monitoring. The facility's policy indicated that residents clinically at risk should be identified and monitored, but this was not adhered to in the case of Resident 7.
Improper Catheter and Drainage Bag Care
Penalty
Summary
The facility failed to ensure proper care for a resident's indwelling urinary catheter and biliary drain, as observed during multiple routine checks. On several occasions, the urinary drainage bag and the biliary drainage bag were found lying on the floor without any covering, contrary to the facility's policy. The bags were observed touching the floor while the resident was in bed and attached to the wheelchair without any covering, which is against the guidelines that require drainage bags to be covered and not touch the floor. The resident involved had a complex medical history, including acute respiratory failure, cellulitis, chronic atrial fibrillation, chronic obstructive pulmonary disease, obstructive sleep apnea, dyspnea, and type 2 diabetes mellitus with diabetic chronic kidney disease. The care plan for the resident included maintaining a closed system with the urinary bag below the bladder and covered, but there were no specific interventions for the biliary drain. Interviews with staff confirmed the expectation that drainage bags should be covered and not touch the floor, yet these practices were not followed, leading to the deficiency.
Improper Cleaning and Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper cleaning and storage of respiratory equipment for a resident, specifically the nasal cannula and CPAP mask and tubing. Observations over several days revealed that the oxygen tubing used for a resident was not dated, and there was no dated storage bag present in the resident's room. Interviews with staff, including an LPN and the Director of Health Services, confirmed that the oxygen tubing was not dated, and the storage bag was only changed monthly. The facility's policy required oxygen cannula and tubing to be stored in a plastic bag when not in use and marked with the date and resident's name. The resident involved had a complex medical history, including acute respiratory failure, chronic obstructive pulmonary disease, obstructive sleep apnea, and other conditions requiring continuous oxygen therapy and CPAP use. Physician orders specified the need for regular cleaning and storage of the CPAP mask and tubing, as well as monthly changes of the oxygen tubing. Despite these orders, the facility did not adhere to the required protocols, leading to the deficiency noted in the report.
Food Safety and Sanitation Deficiency
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food safety during a kitchen observation. Raw hamburger meat was observed on a tray on the bottom of a rolling cart outside of the cooler, alongside prepared salads. The Area Director of Food Services acknowledged that the meat should not have been on the cart and should have been stored in the cooler. The Director of Food Services admitted to removing the hamburger meat from the cooler and placing it on the cart with the salads, but could not recall how long the meat had been out of the cooler. Additionally, during the same observation, an employee was noted to be without a beard covering in the kitchen food product area. The Director of Food Services indicated that the employee had removed the beard covering. The facility's policy, as provided by the Regional Nurse Consultant, requires beard and mustache hair to be covered while in kitchen food product areas, with facial hair restraints required in any production area. The policy also states that potentially hazardous foods that have stood for more than four hours at room temperature are not considered safe and must be discarded.
Improper Glucometer Handling and Sanitation
Penalty
Summary
The facility failed to ensure proper handling and sanitation of a glucometer during medication administration for two residents. During an observation, a registered nurse was seen using a glucometer without placing a barrier under it when placing it on various surfaces, including the medication cart and a resident's side table. The nurse did not sanitize the glucometer between uses for different residents, which is against the facility's policy that requires cleaning and disinfecting the device after each use. Resident 8 and Resident 19, both diagnosed with type 2 diabetes mellitus, were involved in this deficiency. Resident 8 had a physician order to obtain blood glucose readings before meals and at bedtime, while Resident 19 had an order for insulin administration before meals. The lack of proper sanitation and handling of the glucometer was confirmed by a Licensed Practical Nurse, who stated that the glucometer was used for multiple residents and should be cleaned between uses. The facility's policy, provided by the Regional Director of Clinical Services, clearly indicated the requirement for cleaning and disinfecting glucometers when used for multiple residents.
Failure to Arrange Transportation for Medical Appointment
Penalty
Summary
The facility failed to ensure transportation arrangements were made for Resident B, resulting in her missing a medical appointment with her urologist. Resident B, who has chronic kidney disease, hypertensive chronic kidney disease, and obstructive uropathy, was scheduled for a treatment appointment with a urology nurse practitioner. Despite a physician's order to set up transport for the appointment, the necessary arrangements were not made, and the resident missed her appointment. Interviews revealed that the Life Enrichment Director, responsible for resident transport, did not have Resident B on her schedule, and the nursing staff, who were responsible for scheduling transport, found the process time-consuming due to the requirement to use a government website. Additionally, the facility lacked a specific policy on setting up transportation for resident appointments, although the expectation was that staff would arrange transportation for any resident needing it. The Executive Director confirmed that the facility's policy was to provide transportation for all residents requiring it.
Failure to Ensure Dignified Treatment During Personal Care
Penalty
Summary
The facility failed to ensure a resident was treated in a dignified manner during personal care. Certified Resident Care Associate (CRCA) 4 was involved in an incident where she became frustrated with a resident who was combative during personal care. In her frustration, CRCA 4 left the resident's room unattended without informing any other staff members on the unit. She intended to leave the facility but was calmed down by the Employee Experience Manager (EEM) and returned to her unit to complete her shift. The Director of Health Services (DHS) confirmed that CRCA 4 had been disciplined for her actions. The resident involved, identified as Resident B, had a diagnosis of unspecified dementia with behavioral disturbances, including aggression. The resident's care plan included interventions for aggressive behavior during hands-on care. On the day of the incident, Registered Nurse (RN) 5 and CRCA 6 discovered the resident unattended and completed the personal care. The facility's policy on resident rights emphasizes treating residents with dignity and respect, which was not upheld in this situation.
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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