Colonial Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Crown Point, Indiana.
- Location
- 119 N Indiana Ave, Crown Point, Indiana 46307
- CMS Provider Number
- 155733
- Inspections on file
- 30
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Colonial Nursing Home during CMS and state inspections, most recent first.
The facility did not ensure proper verification of dishwasher sanitation levels in the main kitchen when the Dietary Food Manager used faulty test strips that failed to show a discernable color change, leaving the sanitation status unconfirmed for food served to most residents.
Surveyors identified that several rooms did not meet the required minimum square footage per resident, with one single occupancy room measuring less than 100 sq ft and multiple occupancy rooms providing less than 80 sq ft per resident. The Administrator confirmed these rooms had variances and did not meet regulatory standards.
A resident with diabetes and other medical conditions had insulin doses held on several occasions when blood sugar readings were below certain levels, but there were no physician orders for holding the medication, no documentation of physician notification, and no progress notes explaining the held doses. The DON confirmed that refusals should have been documented instead of holding the medication without proper notification.
A resident with severe cognitive impairment, hemiplegia, and type 2 diabetes had a recurring diabetic foot ulcer that was open and receiving wound care per physician orders. Despite recommendations for pressure reduction and repositioning, the facility did not have a comprehensive care plan addressing the diabetic foot ulcer, as confirmed by the DON.
A resident with a history of schizophrenia and neuromuscular dysfunction of the bladder was noted to have persistent redness in the right eye, which was observed by staff and confirmed on multiple occasions. Despite this, there was no documentation of assessment or monitoring of the eye condition in the medical record, and the DON had no additional information regarding the issue.
A resident with a surgically debrided right heel pressure ulcer and complex wound care needs did not have physician orders entered for a wound vac or rescue dressing, despite clinical recommendations and facility policy requiring such documentation. The DON confirmed that the necessary orders were missing from the medical record.
A resident with chronic kidney disease and recent surgery was not placed on a prescribed fluid restriction upon readmission, despite care plan documentation indicating an 1800 mL limit. No physician orders or monitoring of fluid intake were present, and facility policy for fluid restriction was not followed.
A resident with heart failure and other chronic conditions received continuous oxygen despite a PRN order, with no documentation in the MAR or TAR of administration or oxygen saturation monitoring. The DON reported staff kept oxygen on at all times for shortness of breath, and facility policy requiring documentation was not followed.
A nurse was observed discarding used lancets into a regular garbage can instead of a sharps container during blood glucose testing for a resident. Despite being aware of the correct procedure, the nurse repeated this action, which was not in accordance with facility infection control policy as confirmed by the DON.
Surveyors observed unsanitary conditions in the main kitchen, including food splashes and debris on the wall next to the stove top and a buildup of debris on the floor and baseboard under the dishwasher. The DFM confirmed these areas needed a deep clean but had not been addressed due to staffing assignments.
The facility failed to ensure correct PPE use and hand hygiene by staff, impacting residents under Enhanced Barrier Precautions (EBP). Two CNAs did not initially apply necessary PPE when caring for residents with feeding tubes and pressure wounds. Additionally, a CNA did not wash hands between resident care and used the same package of wipes for multiple residents, despite available supplies.
The facility failed to maintain a clean and well-repaired environment on the first floor, with issues such as scraped paint, dried feeding on equipment, and debris on floors. Despite the Housekeeping Completion Form indicating daily cleaning requirements, observed conditions contradicted these protocols, suggesting a failure in the housekeeping process.
The facility failed to ensure a clean and homelike environment for two residents, resulting in soiled bed linens. A resident with chronic obstructive pulmonary disease was found with a dried urine ring under the incontinent pad, while another resident with a urinary catheter and a pressure ulcer had dried blood and drainage on the sheet. These deficiencies were observed during incontinence care by agency staff.
The facility failed to provide timely incontinence care for two residents dependent on staff. One resident was left in a saturated brief and pad from 3:00 a.m. until 7:19 a.m., despite needing maximum assistance. Another resident was found in a similar state, with care delayed until staff intervened. Both residents had care plans indicating incontinence and required assistance for toileting and hygiene.
The facility failed to meet the required square footage per resident in eight rooms, with single rooms measuring less than 100 square feet and multiple rooms providing less than 80 square feet per bed. The Administrator confirmed these rooms had variance waivers and did not meet the required standards.
A facility failed to document catheter care and urinary output for a resident with an indwelling urinary catheter. Despite a care plan and physician's order requiring monitoring every shift, records for March and April lacked documentation. The Infection Preventionist confirmed the absence of documentation, violating the facility's policy on maintaining accurate records and clean techniques.
A cognitively impaired resident was not provided with appropriate activities, despite care plans indicating preferences for music and group activities. Observations showed the resident in a dark room without engagement, and staff interviews revealed a lack of structured one-on-one activities and documentation.
A resident with a history of hemiparesis, hemiplegia, diabetes, and heart failure had two open wounds on her right shin that were not properly assessed or monitored by the facility. Despite physician orders to apply Betadine and monitor the wounds, there was no documentation of assessments until a later date, violating the facility's wound management policy.
A facility failed to implement an Occupational Therapy recommendation for a resting hand splint for a resident with hemiplegia and dementia. The resident was observed without the splint, and there were no physician's orders for it. The Director of Rehab was unaware of the discontinuation, and the DON noted the resident's mother refused the splint, but this was undocumented.
A resident with a PICC line for IV antibiotics did not receive proper line care according to professional standards. The facility failed to document saline flushes before and after antibiotic administration, as required by policy. The DON confirmed the oversight during an interview.
A resident with chronic respiratory conditions was observed receiving an incorrect oxygen flow rate on two occasions, contrary to a physician's order for 3 lpm continuously. The discrepancy was identified and corrected during an observation with the DON.
A facility failed to maintain complete and accurate incontinence care logs for a resident with acute respiratory failure, heart failure, and bipolar disorder. The care plan required documentation every shift, but several days had missing or insufficient entries. Staff acknowledged the lapses and mentioned issues with accessing charting during shifts.
Dishwasher Sanitation Testing Failure in Main Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment by not properly testing the sanitation level of the dishwasher. During an observation, the Dietary Food Manager (DFM) used test strips to check the dishwasher's sanitation level, but the strips did not show a discernable color change as expected. The DFM was unsure why the strips were not working and attempted to use a new package of strips, which also failed to provide a clear result. The DFM indicated that these strips had always been used, but could not explain the malfunction. This deficiency had the potential to affect 26 of 29 residents who received food from the kitchen, as the effectiveness of the dishwasher's sanitation could not be verified at the time of the survey.
Resident Room Size Below Regulatory Standards
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in both single and multiple occupancy rooms, as determined by observation, record review, and interview. Specifically, one single resident room measured only 96.2 square feet, which is below the required 100 square feet. Additionally, several multiple resident rooms were found to have less than the required 80 square feet per resident, with measurements ranging from 70.0 to 75.2 square feet per bed. These deficiencies were identified in eight rooms, some of which were unoccupied at the time of the survey. During an interview, the Administrator confirmed that these rooms had variances and did not meet the required square footage standards.
Failure to Notify Physician When Insulin Held Due to Blood Sugar Levels
Penalty
Summary
The facility failed to notify a resident's physician when insulin doses were held due to blood sugar levels, as required. Record review for a resident with diagnoses including cellulitis, type 2 diabetes, and a pressure ulcer showed that Novolog insulin was ordered to be administered three times daily with meals. However, the Medication Administration Record indicated that the insulin was held on multiple occasions when the resident's blood sugar was below certain levels. There were no physician orders specifying parameters for holding the medication, no progress notes documenting the medication being held, and no evidence that the physician was notified when the insulin was not administered. Interview with the Director of Nursing revealed that the resident often refused insulin based on blood sugar readings, but the nurse should have documented these as refusals rather than holding the medication. The Director of Nursing confirmed there was no further information to provide regarding physician notification or documentation for the held doses.
Failure to Implement Comprehensive Care Plan for Diabetic Foot Ulcer
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with a diabetic foot ulcer. During wound care observation, the resident was found to have an open ulcer on the left lateral foot, which was being treated according to physician orders. The resident's medical record showed a history of hemiplegia, hemiparesis, cognitive communication deficit, and type 2 diabetes mellitus, with severe cognitive impairment and dependence on staff for all activities of daily living. The resident had a recurring diabetic foot ulcer that had healed and reopened multiple times, with the most recent reopening documented in the clinical notes. Despite ongoing wound care and recommendations for pressure reduction and repositioning, the resident's record did not contain a comprehensive care plan specifically addressing the diabetic foot ulcer. The existing care plan only addressed general risk for skin integrity issues and did not include specific interventions for the current wound. The Director of Nursing confirmed that there was no care plan in place for the diabetic foot ulcer at the time of the survey, despite the wound being open and under treatment.
Failure to Assess and Monitor Resident's Eye Condition
Penalty
Summary
A resident with diagnoses including schizophrenia and neuromuscular dysfunction of the bladder was observed to have a solid red discoloration on the bottom portion of the sclera in her right eye. The resident reported that the redness had been present for some time, though she was initially unaware of it until nursing staff pointed it out. Observations on two separate occasions confirmed the persistent redness. Review of the resident's medical record revealed no documentation of assessment or monitoring of the right eye discoloration. During an interview, the DON confirmed there was no further information available regarding the resident's red eye. The deficiency was identified due to the facility's failure to assess and monitor the resident's eye condition as required, despite clear evidence of an ongoing issue.
Failure to Obtain Physician Orders for Wound Vac and Dressing
Penalty
Summary
A resident with a history of cellulitis of the right lower limb, type 2 diabetes mellitus, and an unstageable pressure ulcer to the right heel was observed to have a wound vac placed to the right heel following a recent hospital admission and surgical debridement due to infection. The wound vac was to be continued at 100 mmHg per the surgeon's request, with a rescue dressing of calcium alginate with silver, and specific instructions for dressing changes and wound care were documented in the Skin and Wound Note. Despite these clinical recommendations and the resident's complex wound care needs, there were no corresponding physician's orders for the wound vac or rescue dressing in the medical record for the month. The Director of Nursing confirmed that such orders should have been entered. Facility policy requires that wound treatments and physician's orders be documented in the medical record for residents with skin impairments, but this was not done for the resident in question.
Failure to Implement and Monitor Fluid Restriction for Resident
Penalty
Summary
A resident with a history of chronic kidney disease, type 2 diabetes mellitus, and multiple skin conditions was recently readmitted to the facility following surgery and an infection requiring antibiotic therapy. The resident reported having been on a fluid restriction while hospitalized, but upon return to the facility, no such restriction was enforced. Observation revealed a large cup of water at the bedside, and the resident confirmed she was not on a fluid restriction since her return. Record review showed that the resident's care plan included a regular no added salt thin liquid diet with an 1800 milliliter fluid restriction. However, there were no physician orders or documentation regarding fluid intake or restriction in the resident's record. Facility policy required specific instructions and monitoring for fluid restrictions, including removal of water pitchers and documentation of intake, but these procedures were not followed for this resident.
Failure to Provide and Document Appropriate PRN Oxygen Administration
Penalty
Summary
A resident with diagnoses including type 2 diabetes mellitus, heart failure, and hypertension was observed on two occasions receiving continuous oxygen via nasal cannula at a flow rate of 2 liters. The physician's order specified oxygen at 2 liters via nasal cannula as needed (PRN) for shortness of breath, with instructions to maintain oxygen saturation above 90. The resident's care plan also indicated oxygen should be administered as ordered due to the risk of altered oxygen levels from heart failure. Despite these orders, the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the month lacked documentation that PRN oxygen had been administered or that the resident's oxygen saturation had been monitored. The resident was cognitively impaired and dependent on staff for all activities of daily living. During an interview, the DON stated that staff kept the oxygen on at all times due to the resident's shortness of breath during care activities, and indicated an intention to update the oxygen orders. Facility policy required documentation of oxygen administration details, but this was not found in the records.
Improper Disposal of Used Lancets During Blood Glucose Testing
Penalty
Summary
A registered nurse was observed performing blood glucose testing on a resident and failed to follow proper infection control procedures regarding the disposal of used lancets. After checking the resident's blood sugar, the nurse discarded the used lancet into a regular garbage can next to the resident's bed instead of using the designated sharps container. This action was observed twice during the same encounter, despite the nurse acknowledging during interviews that the lancets should have been disposed of in the sharps container as per facility policy. The facility's policy on obtaining a fingerstick glucose level clearly states that used lancets must be disposed of in sharps disposal containers. The Director of Nursing confirmed during an interview that the nurse's actions were not in accordance with this policy. The incident involved a resident undergoing blood glucose monitoring, and the nurse's repeated failure to use the sharps container constituted a breach of infection control practices.
Unsanitary Conditions Observed in Main Kitchen
Penalty
Summary
The facility failed to maintain a sanitary, safe, and homelike environment in the main kitchen, as evidenced by dirty kitchen walls and floors. During an initial kitchen tour with the Dietary Food Manager (DFM), surveyors observed that the wall next to the stove top was covered in splashed food and debris, and the floor and baseboard underneath the dishwasher were dirty and had a buildup of debris. The DFM acknowledged during the interview that these areas required a deep clean and explained that he had not had time to address them because he was not scheduled to be the main cook that day.
Inadequate PPE Use and Hand Hygiene in LTC Facility
Penalty
Summary
The facility failed to ensure the correct use of Personal Protective Equipment (PPE) by staff members when providing care to residents under Enhanced Barrier Precautions (EBP). Agency CNA 1 and Agency CNA 5 were observed entering the rooms of residents requiring EBP without initially applying the necessary PPE. Both CNAs were unaware of the EBP requirements until they noticed the signs outside the residents' rooms. Resident D and Resident F, both with diagnoses including stroke and requiring EBP due to feeding tubes and pressure wounds, were involved in these incidents. The facility's policy, which mandates the use of gloves and gowns for high-contact care activities, was not followed. Additionally, the facility failed to ensure proper hand hygiene and the exclusive use of personal care items for individual residents. Agency CNA 2 did not wash her hands after providing incontinence care to Resident B before proceeding to care for Resident C. Furthermore, the same package of cleansing wipes was used across multiple residents, including Residents B, C, G, D, and H, despite the availability of additional supplies in the storeroom. This practice was contrary to the facility's hand hygiene policy, which aims to prevent the spread of infections.
Environmental Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment for residents, staff, and the public on the first floor. During an environmental tour, several deficiencies were observed, including scraped paint, nicks, and gouges on the walls in multiple rooms. Additionally, dried feeding was found on feeding pump poles, an oxygen concentrator, and the floor. Debris and trash were present on the floors, and a dirty floor mat and a stool with a cracked vinyl seat were noted. These observations were made in the presence of the Director of Maintenance/Housekeeping, who acknowledged the issues and provided explanations for some of the deficiencies, such as the presence of cords preventing mopping and the possibility that the housekeeper had not yet cleaned the room. The Housekeeping Completion Form indicated that rooms were to be dusted, swept, and mopped daily, including underneath the bed, and that walls, furniture, and bedrails were to be cleaned daily. However, during an interview, a housekeeper stated that the rooms on the first floor had all been cleaned, which contradicted the observed conditions. This discrepancy suggests a failure in the housekeeping process, as the observed conditions did not align with the facility's cleaning protocol. The citation relates to a specific complaint, indicating that these issues were part of a broader concern raised by stakeholders.
Failure to Maintain Clean and Homelike Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two residents, resulting in soiled bed linens. During an observation, Agency CNA 2 provided incontinence care to Resident B and discovered a dried urine ring under the resident's incontinent pad, indicating that the bottom sheet had not been checked or changed earlier. Resident B's medical records showed a diagnosis of chronic obstructive pulmonary disease, a moderately impaired cognitive status, and dependency for toileting, with consistent incontinence of bowel and bladder. In another instance, Agency CNA 2 and RN 1 provided incontinence care to Resident D, who had a urinary catheter and was incontinent of bowel. They observed dried blood and other drainage on the sheet under the resident's knee, which RN 1 acknowledged. Resident D's records indicated a history of stroke, a urinary catheter, and a stage three pressure ulcer on the left knee. The care plan required treatment for the pressure ulcer, which had been completed the previous day. These observations were part of a complaint investigation.
Failure to Provide Timely Incontinence Care for Residents
Penalty
Summary
The facility failed to provide timely incontinence care for two residents who were dependent on staff for activities of daily living. Resident E was observed with a saturated incontinence brief and pad, along with dried urine on the sheets, indicating a lack of timely care. Despite being informed by Agency CNA 2 that incontinence care was last provided at 3:00 a.m., the resident remained in a soiled state until 7:19 a.m. when CNA 3 and LPN 4 finally completed the care. Resident E's care plan indicated urinary incontinence with interventions for care as needed, and the resident's MDS assessment showed a severely impaired cognitive status, requiring maximum assistance for toileting and hygiene. Similarly, Resident F was found with a saturated incontinence brief, top sheet, and lift sheet, with urine rings on the bottom sheet. The care was delayed until Agency CNA 5 and LPN 4 addressed the situation. Resident F's care plan also noted bladder incontinence with interventions for care as needed, and the MDS assessment indicated a moderately impaired cognitive status, with dependency for toileting and hygiene. These observations were part of a complaint investigation, highlighting the facility's failure to ensure timely incontinence care for residents dependent on staff.
Deficiency in Room Square Footage Requirements
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in both single and multiple occupancy rooms, as evidenced by observations, record reviews, and interviews. Specifically, eight out of thirty resident rooms did not meet the regulatory requirements of at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. The deficiency was observed in rooms 101, 104, 111, 201, 202, 204, 206, and 208. For instance, a single resident room measured only 96.2 square feet, while multiple resident rooms had less than the required 80 square feet per bed, with measurements ranging from 70.0 to 75.2 square feet per bed. During an interview, the Administrator acknowledged that these rooms had variance waivers and did not meet the required square footage.
Failure to Document Catheter Care and Urinary Output
Penalty
Summary
The facility failed to ensure proper catheter care and documentation for a resident with an indwelling urinary catheter. The resident, who had diagnoses including cerebral infarction, type 2 diabetes mellitus, and malignant neoplasm of the prostate, was admitted with cognitive impairment and an indwelling urinary catheter. The care plan required monitoring and documenting intake and output, and a physician's order specified monitoring every shift. However, the Medication Administration Records (MAR) and Treatment Administration Records (TAR) for March and April lacked documentation of catheter care or urine output. During an interview, the Infection Preventionist confirmed the catheter order included monitoring every shift but could not provide documentation that catheter care was completed or urinary output was recorded. The facility's policy on urinary catheter care emphasized maintaining an accurate record of daily output and using clean techniques when handling the catheter. Despite these guidelines, the facility did not document the date and time of catheter care, the name and title of the caregiver, or any assessment data, leading to the deficiency citation.
Failure to Implement Activities for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement appropriate activities for a cognitively impaired resident, identified as Resident 14, who was observed multiple times lying in bed with no engagement or stimulation. The resident, diagnosed with stroke, aphasia, and depression, was noted to be severely cognitively impaired and dependent on staff for all activities of daily living. Despite having care plans that indicated the resident's preferences for listening to music, keeping up with the news, and participating in group and religious activities, the resident was not provided with these opportunities. Observations showed the resident in a dark room without any music or television, and there was no evidence of staff facilitating activities that aligned with her preferences. Interviews with staff revealed a lack of structured one-on-one activities for the resident. The CNA indicated that the resident did not participate in activities outside her room and that the roommate's preferences limited the use of television or lights. The Activity Director admitted to not having a set curriculum for one-on-one activities and had not documented any such visits. Furthermore, the Activity Director did not provide a copy of the most recent Activity Assessment for the resident, indicating a lack of proper documentation and follow-through on the resident's activity needs.
Failure to Monitor and Document Wound Care
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a resident's wounds, leading to a deficiency in care. Resident 10, who has a medical history including hemiparesis, hemiplegia, diabetes mellitus, and heart failure, was observed with two open areas on her right shin. These areas were initially fluid-filled blisters that had opened. Despite the presence of these wounds, there were no progress notes related to their assessment or monitoring, indicating a lapse in the facility's wound management protocol. The resident's medical record showed that a physician's order was given to apply Betadine to the open blisters and monitor them until resolved. However, the facility did not document any assessments or monitoring of the wounds until the Wound Nurse Practitioner assessed them on a later date. This lack of documentation and monitoring is contrary to the facility's policy, which requires that residents with skin impairments have appropriate interventions and treatments documented in the medical record. The deficiency was identified during a survey, highlighting the facility's failure to adhere to its own skin and wound management system.
Failure to Implement Occupational Therapy Recommendation for Resting Hand Splint
Penalty
Summary
The facility failed to follow up on an Occupational Therapy recommendation for a resting hand splint for a resident with hemiplegia, hemiparesis, and unspecified dementia. The resident was observed without a splint in place, despite a previous Occupational Therapy Discharge Summary indicating the need for a resting hand splint for 5 hours a day to manage joint protection and contracture. There were no physician's orders for the splint, and the Director of Rehab was unaware of why the splint was not continued after therapy discharge. The Director of Nursing indicated that the resident's mother had been trained on the splint's use but refused its application, and there was no documentation of this refusal in the resident's record.
Deficiency in PICC Line Care for Resident
Penalty
Summary
The facility failed to adhere to professional standards of practice in the care of a PICC line for a resident receiving intravenous antibiotics. On observation, the resident was found with a PICC line in her right upper arm, receiving antibiotics following surgery. The resident's medical history included hypertension, abdominal aortic aneurysm, and major depressive disorder, and she was noted to be cognitively impaired. The care plan indicated the need for IV antibiotics for a urinary tract infection and specified that the PICC line should be flushed as needed or per policy. However, the physician's orders did not include instructions to flush the PICC line with saline before and after administering the antibiotic medication, which is a standard practice to maintain line patency. The Medication Administration Record showed that while the antibiotic was administered as ordered, the saline flushes were only documented once per shift, lacking evidence of flushing before and after medication administration. During an interview, the DON acknowledged that the PICC line should have been flushed before and after antibiotic administration, indicating a lapse in following the facility's policy on medication infusion.
Failure to Maintain Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident by not adhering to the prescribed oxygen flow rate. Resident 22, who has chronic respiratory failure and chronic obstructive pulmonary disease, was observed on two occasions with an incorrect oxygen flow rate. On one occasion, the oxygen concentrator was set at 2 liters per minute (lpm), and on another, it was set at 2.5 lpm, despite a physician's order from July 16, 2023, indicating the resident should receive oxygen at 3 lpm continuously. The discrepancy was noted during an observation with the Director of Nursing, who then adjusted the flow rate to the correct setting.
Incomplete Incontinence Care Documentation
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate regarding incontinence care logs. Resident B, who had diagnoses including acute respiratory failure, heart failure, and bipolar disorder, was admitted to the facility and required assistance with toileting due to occasional incontinence of bowel and bladder. The care plan indicated that the resident needed staff assistance for various activities of daily living, including toileting. However, the January 2024 tasks showed inconsistent documentation of incontinence care, with several days missing entries and others having fewer entries than required. The Nurse Manager confirmed that documentation should have been done at least every shift, three times a day, but this was not consistently followed. During interviews, the Nurse Manager, Director of Nursing, and Administrator acknowledged the documentation lapses. The Administrator mentioned that staff had reported issues with accessing charting during their shifts, leading to the implementation of a tablet for charting. Despite this, the facility could not provide additional information to explain the incomplete records. This deficiency was identified during a complaint investigation related to Resident B's care.
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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