Community Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 5600 E 16th St, Indianapolis, Indiana 46218
- CMS Provider Number
- 155029
- Inspections on file
- 30
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Community Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions experienced repeated water leakage from a faulty sink drainpipe in his room, leading to water damage, unsafe wet floors, and an unclean environment. Despite multiple notifications to maintenance and a submitted work order, the issue persisted for months, with staff regularly addressing flooding and water damage but no repairs completed.
A resident with complex medical needs accused a CNA of causing a flooded room and of physical abuse following a verbal exchange. Although the incident was reported internally to the DNS and ED, the required notification to the state health department (IDOH) was delayed until the day after the event, contrary to facility policy mandating immediate reporting of abuse allegations.
A resident with multiple chronic conditions who was dependent on staff for ADL assistance did not receive timely incontinent care. Despite activating her call light and reporting concerns, the resident was left in urine for extended periods, and staff found her brief and pads soaked during an observation. The issue persisted even after being reported through a grievance process.
Two residents experienced deficiencies in accident prevention and supervision: one was injured when a CNA transporting her in a wheelchair struck her foot against a wall, and another left the facility alone despite orders requiring a responsible party, due to a lack of monitoring and clear policies. The facility did not have policies for safe wheelchair transport or accident prevention, contributing to these incidents.
A resident with multiple chronic conditions did not receive oxygen therapy as ordered, and the oxygen tubing and humidifier bottle were found on the floor without proper dating. The resident reported waiting for new supplies and noted ongoing issues with the oxygen concentrator. Staff confirmed that the required care and equipment maintenance had not been provided, resulting in a deficiency related to respiratory care.
A resident with a history of seizures and anxiety did not receive multiple physician-ordered anti-convulsant and anti-anxiety medications for three consecutive days due to unavailability, with no documentation of efforts to resolve the issue or notify appropriate parties. The resident experienced increased seizure activity and required hospital transfer, and facility leadership was unaware of the problem until after the incident.
A resident with cognitive impairment and multiple medical conditions was denied their request for chocolate milk by a CNA, who cited concerns about incontinence and time constraints. The refusal was witnessed by an LPN and confirmed by the resident, demonstrating a failure to honor the resident's right to choose their food preferences as outlined in facility policy.
A resident with polyneuropathy was observed with thick, yellowing toenails despite a recent podiatry visit that included a recommendation for daily urea 40% cream. The order for the cream was not entered into the clinical record, as the DON was not made aware of the recommendation, resulting in the treatment not being implemented.
Surveyors identified deficiencies in kitchen operations, including uncovered and undated food items, improper staff hygiene such as failure to wear beard nets, and uncovered trash cans with food waste. These issues were observed during kitchen inspections and meal service, with staff interviews confirming a lack of instruction and adherence to facility policies on food storage, cleanliness, and personal hygiene.
Multiple residents reported being treated roughly or disrespectfully by staff, including being rushed during care, handled roughly, and spoken to in a disrespectful manner. One resident with mental illness described being singled out and denied assistance with daily tasks. Additionally, three residents were observed with tablecloths tied around their necks instead of proper clothing protectors during meals, despite appropriate supplies being available. These incidents reflect a failure to maintain resident dignity and respect as required by facility policy.
Multiple cognitively intact residents, including those with complex medical conditions, reported that meals were frequently served cold or at inappropriate temperatures. Resident council meetings and interviews confirmed ongoing dissatisfaction with food temperature, and a test tray revealed food items outside of safe temperature ranges. Despite grievances, the issue persisted among several residents.
Two residents who were cognitively intact filed grievances—one regarding missing personal items and another about a wandering, incontinent resident entering his room. In both cases, staff failed to follow up or maintain the required grievance documentation, and the forms could not be located as required by facility policy.
Two residents were involved in an incident where one, with a history of sexually inappropriate behaviors, was able to enter another's room and inappropriately touch and kiss her despite prior documented incidents and the need for one-on-one supervision. Staff found the female resident in distress and intervened, but supervision lapses were observed even after the event, resulting in a failure to protect residents from abuse.
The facility did not maintain complete evidence of a thorough abuse investigation after two residents were involved in an incident of alleged inappropriate sexual contact. Although the incident was witnessed by CNAs and reported by a supervisor, the investigation file lacked a required written statement from the supervisor, contrary to facility policy.
Two residents with new psychiatric diagnoses were not promptly referred for required PASRR Level 1 or Level 2 assessments after their conditions changed and new psychotropic medications were started. The facility did not update PASRR screenings as required by policy following significant changes in mental health status.
Two residents did not receive timely assistance with ADLs: one resident with hemiplegia was not promptly repositioned in bed despite repeated requests to staff, and another resident did not consistently receive scheduled showers or partial baths as outlined in her care plan. Staff interviews and documentation confirmed these lapses in care.
Multiple residents did not receive prescribed medications and treatments as ordered, including missed doses of immunosuppressive medication due to unavailability, unadministered insulin without provider notification or documentation, and improper application of rectal cream by a CNA instead of a licensed nurse.
A resident with chronic respiratory failure and hemiplegia was observed not receiving oxygen as ordered, with the nasal cannula out of place and the oxygen concentrator set to five liters instead of the prescribed two liters. The QMA was unable to adjust the oxygen level and did not report the issue to a nurse before leaving the room, resulting in the resident receiving incorrect oxygen therapy.
Two residents with chronic conditions experienced significant delays in receiving prescribed pain medications, with one waiting over five hours for Tylenol and another reporting repeated waits of 30 minutes to an hour for hydrocodone. LPNs were observed prioritizing other tasks or residents before addressing pain requests, despite being notified by staff or the residents themselves.
A resident with severe dementia and behavioral disturbances, including wandering and incontinence, repeatedly entered another resident's room and used their bed, causing distress. Although staff were aware of these behaviors and discussed possible interventions like stop signs, the incidents were not documented in the clinical record, and the care plan was not updated with new strategies. The facility did not implement or record new interventions as required by its behavior management policy.
A resident with a history of stroke did not receive timely follow-up on pharmacy recommendations regarding discontinuation of fenofibrate and necessary lab work, as the facility could not provide evidence that the ordered lipid panel was completed. Additionally, the resident was prescribed two prophylactic antibiotics simultaneously without clear documentation or rationale, and the DON could not explain the continued use or confirm urology consultation.
Surveyors found that insulin vials for three residents with diabetes were not labeled with open or expiration dates on a medication cart, despite facility policy requiring such labeling. A nurse confirmed that insulin should have open dates, and the issue was identified through observation, record review, and staff interview.
Staff failed to perform hand hygiene before administering eye drop medications to two residents, handling multiple surfaces and items before medication administration. In another instance, a resident with a colostomy and under Enhanced Barrier Precautions kept open containers of urine and feces on the bedside table, and a nurse consultant removed these without wearing a gown as required by policy.
Three residents experienced environmental deficiencies, including broken blinds, persistent urine odor, and scraped paint in their rooms. Staff were aware of these issues, with maintenance and housekeeping supervisors confirming the problems and indicating ongoing challenges with repairs and odor control. The facility lacked a specific policy for maintaining a homelike environment.
The facility failed to serve breakfast at safe and palatable temperatures, affecting 54 of 55 residents. Observations revealed that food items, including eggs and sausage patties, were served at temperatures below the required 135 degrees Fahrenheit. Residents reported that breakfast was often served cold, and the facility's Food Temperatures Policy was not consistently followed.
The facility failed to maintain the first-floor shower room in good condition and did not timely repair a leaking pipe in the kitchen, potentially affecting all 55 residents. Observations revealed a leaking pipe with rusted clamps and a dirty, stained shower room floor. The Executive Director and Maintenance Supervisor confirmed these conditions.
A resident with dementia and heart failure was observed wearing the same ill-fitting clothing over several days, despite a care plan indicating the need for assistance with ADLs. Staff interviews confirmed the resident would change clothes if approached correctly, but timely assistance was not provided.
The facility failed to properly assess and manage the care of a resident with multiple medical conditions, including not administering prescribed insulin and antipsychotic medications as ordered, and not documenting or addressing a skin condition. Another resident with constipation did not receive prescribed medications, and bowel movements were not monitored as required by the care plan.
The facility failed to provide oral care as ordered by the physician and did not timely obtain a physician's order for gastrostomy tube site care for a resident. Observations revealed dried brown drainage at the base of the resident's g-tube and a white film on their teeth and lips, indicating a lack of proper care. Interviews confirmed that oral and g-tube site care were not consistently provided, and the DNS acknowledged the absence of a physician's order for g-tube site care.
The facility failed to adequately monitor and document behaviors for a resident with schizoaffective disorder and another with schizophrenia, leading to repeated incidents of inappropriate behavior and verbal aggression. Interventions were insufficient and not effectively documented, and the facility's behavior management policy was not consistently followed.
The facility failed to maintain a medication error rate below 5 percent, resulting in a 5.88% error rate. An LPN did not follow proper procedures for blood sugar monitoring and insulin administration for a resident with type 2 diabetes, leading to medication errors.
Failure to Maintain Resident Room in Good Repair Resulting in Unsafe and Unclean Environment
Penalty
Summary
The facility failed to maintain a resident's room in good repair, resulting in repeated water leakage from a faulty drainpipe connected to the sink in the resident's room. The issue was observed to cause water damage to the wall, including ripples, bubbles, peeling paint, missing baseboard, and discoloration. The resident reported that the leak had been ongoing since he moved into the room and that he had notified the maintenance director multiple times, including submitting a work order eight months prior, but the problem persisted. Staff routinely had to address water flooding into the hallway by placing wet floor signs and using towels to prevent slips. The housekeeping supervisor confirmed awareness of the wall's condition and noted that renovations had not yet begun as planned. The resident involved had significant medical conditions, including major depressive disorder, cirrhosis of the liver, a liver transplant, severe alcohol dependence, and chronic kidney disease. On one occasion, the water leak triggered a confrontation between the resident and a CNA, with the resident accusing the CNA of causing the flooding and alleging physical abuse, which was denied by the CNA and not substantiated by staff interviews. The ongoing water leakage and lack of timely repair contributed to an environment that was not safe, clean, or homelike, as required by resident rights policies.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident abuse involving a resident with multiple complex medical diagnoses, including major depressive disorder, cirrhosis of the liver, liver transplant, severe alcohol dependence, and chronic kidney disease. On the morning in question, a CNA was accused by the resident of causing water to flood the room and subsequently of pushing him after a verbal exchange. The CNA denied leaving the water running or pushing the resident, stating she was several feet away when the resident moved himself into his wheelchair. The incident was documented in the nurse's note, and the CNA reported the situation to the DNS, who then reported it to the Executive Director (ED). Statements were written and left in the ED's office, and the resident was monitored and found to be in good spirits later that day. Despite the facility's policy requiring immediate reporting of abuse allegations to the ED and the Indiana Department of Health (IDOH), the allegation was not reported to the IDOH until the following day, after the ED became aware of the situation. Interviews confirmed that the DNS reported the incident to the ED on the day it occurred, but the ED did not report to the IDOH until the next day. The facility's policy clearly states that all abuse allegations must be reported to the ED immediately and to the state agency within two hours if abuse or serious bodily injury is involved. This delay in reporting constituted a failure to follow established protocols for timely notification of suspected abuse.
Failure to Provide Timely Incontinent Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including heart failure, peripheral vascular disease, diabetes, muscle weakness, anxiety disorder, and major depressive disorder, did not receive timely incontinent care despite being dependent on staff for activities of daily living (ADLs). The resident's care plan required staff assistance with grooming, hygiene, toileting, and incontinent care as needed. Documentation and interviews revealed that the resident frequently activated her call light for assistance but was often left in urine and bowel movement for extended periods. The resident reported these incidents through a grievance form and directly to the admission coordinator, stating that the issue persisted even after the grievance was marked as resolved. During an observation and interview, the resident indicated she had been lying in urine for an hour before staff responded to her call light. Upon entering, staff found her brief and two cloth pads soaked in urine. The admission coordinator confirmed ongoing reports from the resident about delayed responses to her care needs, which were communicated in morning meetings. The Director of Nursing Services stated that the facility's expectation was for incontinent care to be provided immediately when needed, but this standard was not met in the resident's case.
Failure to Prevent Accident Hazards and Inadequate Supervision
Penalty
Summary
The facility failed to ensure safe transportation of a resident in a wheelchair and did not provide adequate monitoring to prevent a resident from exiting the facility without a responsible party. One resident, who had diagnoses including heart failure, peripheral vascular disease, diabetes, muscle weakness, anxiety disorder, and major depressive disorder, was dependent on staff for wheelchair transport. In September, a CNA accidentally hit the resident's right foot against a wall while turning into the resident's room, resulting in pain and swelling. Although an x-ray showed no fracture at that time, the resident later returned from the hospital with a fractured right toe. The CNA and the Director of Nursing Services (DNS) confirmed the incident, but no safety training or interventions were implemented to prevent recurrence. Additionally, the facility lacked a policy on transporting residents in wheelchairs. Another resident, with diagnoses including schizoaffective disorder, bipolar type, post-traumatic stress disorder, and anxiety, left the facility alone and went to a nearby gas station for snacks. The resident was cognitively intact according to the most recent assessment, but his physician's orders specified that he should only leave with a responsible party. Staff found the resident between the facility's front doors upon his return and assessed him for injuries, finding none. The resident's care plan was updated after the incident, and a wanderguard was applied for safety. The physician noted that the resident had a history of impulsive behavior and poor decision-making, and did not recommend independent leave of absence due to the risk of injury. Interviews with facility leadership revealed that there was no accident policy in place and no specific policy for transporting residents in wheelchairs. The facility's leave of absence policy required a physician's order and specified that residents should only leave with a responsible party unless an independent leave of absence was ordered. The lack of adequate supervision and absence of clear policies contributed to the deficiencies identified for both residents.
Failure to Provide Ordered Oxygen Therapy and Maintain Sanitary Equipment
Penalty
Summary
The facility failed to provide oxygen therapy as ordered by the physician and did not maintain the oxygen tubing and humidifier bottle in a sanitary manner for a resident with multiple medical conditions, including heart failure, peripheral vascular disease, diabetes, muscle weakness, anxiety disorder, and major depressive disorder. The resident's care plan required oxygen administration as ordered, and the physician's order specified oxygen at 3 liters per nasal cannula every shift, with tubing and humidity to be changed weekly and dated. During observation and interview, the resident's oxygen tubing and humidifier bottle were found lying on the floor without dates, and the resident reported waiting for an hour for new supplies. The resident also stated that the oxygen concentrator had been broken for a long time and that the humidifier bottle was always placed on the floor. Staff interviews confirmed that the nurse was responsible for maintaining the resident's oxygen equipment, but the required care had not been provided. The Assistant Director of Nursing Services (ADNS) responded by bringing new, dated supplies and attempted to address the broken concentrator. The resident's oxygen saturation was measured at 92-94% without oxygen and increased to 99% when oxygen was provided. The Director of Nursing Services (DNS) stated that staff were expected to ensure residents received oxygen as ordered and that equipment should be dated, confirming that facility expectations were not met in this instance.
Failure to Provide Physician-Ordered Medications Resulting in Increased Seizure Activity
Penalty
Summary
The facility failed to ensure that a resident with a history of traumatic brain injury, seizures, general anxiety, and aphasia received physician-ordered anti-convulsant and anti-anxiety medications for three consecutive days following admission. The resident was dependent on staff for most activities of daily living and was nonverbal with severe cognitive impairment. Despite clear physician orders for multiple medications, including Phenobarbital, Ativan, Vimpat, Dilantin, and olanzapine, the medication administration record (MAR) and progress notes indicated that these medications were not available and were not administered as ordered. During the period in question, the MAR showed that several doses of the prescribed medications were missed, and there was no documentation of any steps taken by staff to resolve the unavailability of the medications. There was also no evidence that the pharmacy, physician, responsible party, or facility administration were notified about the missing medications. The facility's Director of Nursing (DON) confirmed that she was unaware of the issue until after the resident experienced increased seizure activity and was sent to the emergency room. The DON also stated that there was no formal investigation or additional staff training following the incident, and she was unable to locate documentation reflecting any attempts to address the medication access problem. Progress notes documented that the resident experienced multiple seizures during the period when medications were not administered, leading to a transfer to the hospital for evaluation and treatment. Interviews with facility leadership revealed a lack of specific policies regarding actions to take when medications are unavailable, and there was no documentation to substantiate the administration of certain doses. The facility did have a general policy on medication administration, but it did not address the specific situation of missing medications.
Resident Food Choice Not Honored by Staff
Penalty
Summary
A deficiency occurred when a resident's right to self-determination and choice regarding food selection was not honored. The resident, who had diagnoses including encephalopathy, hemiplegia, and dysphagia, and required substantial assistance with activities of daily living, requested chocolate milk during dining service. Certified Nurse Aide (CNA) 2 refused the request, stating that the chocolate milk would upset the resident's stomach and that they did not have time to address the resulting incontinence. This interaction was witnessed by an LPN and corroborated by the resident, who recalled being denied the chocolate milk by CNA 2. The facility's policy on Preferences for Daily Routine requires that resident preferences be identified and incorporated into the plan of care, with information shared among the interdisciplinary team. Despite this policy, CNA 2 did not honor the resident's preference for chocolate milk, instead making a decision based on perceived inconvenience and the resident's incontinence. The incident was reported to the Indiana Department of Health and documented in the facility's investigation file.
Failure to Implement Podiatry Recommendation for Foot Care
Penalty
Summary
The facility failed to timely implement a podiatry recommendation for a resident diagnosed with polyneuropathy. The resident had a physician's order to be seen by a podiatrist and was observed to have thick, yellowing, crusty toenails on both big toes. A podiatry note documented that the resident's toenails had been debrided and recommended a new order for urea 40% cream to be applied daily to all toenails for sixty days. However, the clinical record did not contain an order for the urea cream, and the DON confirmed she had not been made aware of the recommendation and that the order for the cream had not been processed.
Deficiencies in Kitchen Food Storage, Cleanliness, and Staff Hygiene
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen related to food storage, cleanliness, and staff hygiene. During inspections, various food items in the walk-in refrigerator and dry storage were found uncovered, undated, and open to air, including butterscotch pudding, macaroni and cheese, beef base, juices, salad dressings, deli meats, and thawed meats. Some containers were not labeled with the date opened or a discard date, and several items were not properly covered. The dry storage area also had a bin of oats without a lid and a sticky substance on the floor, which staff acknowledged had been present for some time. Staff interviews revealed a lack of instruction on proper dating and covering of food items, despite the existence of facility policies requiring these practices. Additionally, staff were observed not adhering to personal hygiene standards while handling food. One dietary aide was seen serving food with a beard net around his neck rather than covering his facial hair, contrary to facility policy. The dietary manager confirmed that staff with facial hair are required to wear beard restraints while preparing and serving food. These lapses in hygiene practices were directly observed during meal service. The facility also failed to maintain proper waste management in the kitchen and dry storage areas. Trash cans containing food waste were found uncovered and unattended in both the dry storage and soiled dish areas. In some cases, the lids were present but not in use, and staff were unsure about the requirements for covering trash cans. Facility policy mandates that all trash containers be lined and kept covered with lids when not in use, but this was not consistently followed during the survey.
Failure to Maintain Resident Dignity and Respect During Care and Dining
Penalty
Summary
The facility failed to maintain resident dignity and respect for multiple residents, as evidenced by observations, interviews, and record reviews. Several cognitively intact residents reported that staff were rough or disrespectful during care. One resident described staff as rushing and handling her roughly, while another reported that a CNA dug her nails into his skin during incontinent care. Additional residents indicated that staff had poor attitudes, were not polite, and sometimes yelled at them for using the call light. These interactions were described as disrespectful and lacking in consideration for the residents' comfort and dignity, though not necessarily abusive. Further, a resident with a history of mental illness reported being treated differently by staff due to her higher level of independence. She stated that a CNA refused to assist with tasks such as making her bed or doing laundry, and would provide minimal assistance with meals and water, allegedly to upset her. The resident filed grievances regarding this treatment and requested not to be cared for by the CNA in question. Staff interviews confirmed knowledge of resident rights and abuse training, but also revealed strained relationships and inconsistent care practices. During a dining observation, three residents with dementia or dysphagia were found with tablecloths tied around their necks as makeshift clothing protectors while waiting for their meals, despite the facility having proper clothing protectors available. Staff interviewed were unsure why this practice was occurring. Facility policy requires residents to be treated with consideration, respect, and dignity, but these incidents demonstrate a failure to uphold these standards for several residents.
Failure to Serve Food at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and safe temperatures for multiple residents. Observations, interviews, and record reviews revealed that several cognitively intact residents reported receiving food that was cold or not at an appropriate temperature. Specific examples included residents stating that their meals, such as eggs and sandwiches, were served cold, and that the quality of meals was inconsistent. Resident council meeting minutes and interviews further confirmed that concerns about food temperature were widespread among residents. During a test tray observation, the Regional Culinary Manager measured food temperatures and found that a tenderloin sandwich was below the proper holding temperature, while pears were above the proper holding temperature. Residents had filed grievances regarding the food temperature, but reported that the issue persisted. The deficiency was identified for several residents with various medical conditions, including cellulitis, liver transplant, major depressive disorder, acute respiratory failure, diabetes mellitus, and stroke, all of whom were cognitively intact and able to communicate their concerns.
Failure to Follow Up and Maintain Resident Grievances
Penalty
Summary
The facility failed to follow up on grievances for two residents who were cognitively intact. One resident reported filing grievances regarding missing personal items, including an arm sling, backpack, purse, and a box of crackers, but did not receive any follow-up from the facility. The Social Services Consultant and Social Services Director were unable to locate the grievances, and the Director did not know where the original forms were kept. Another resident reported an incident where another resident, who was known to wander, entered his room and sat on his bed. The resident was upset due to the other resident's incontinence and requested his sheets be changed. He informed a CNA and the Weekend Supervisor, who completed a grievance form and placed it in a designated location for the DON to review. However, the DON did not recall seeing the grievance, and the Executive Director and Social Services Consultant could not locate the form. The facility's policy required all grievance forms to be signed off by the Executive Director/Grievance Official and maintained on-site for at least three years, but this procedure was not followed.
Failure to Prevent Sexual Abuse Between Residents Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect two residents from abuse, specifically sexual abuse, as evidenced by multiple documented incidents involving one resident inappropriately touching and attempting to kiss and fondle another resident. One resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and PTSD, exhibited escalating sexually inappropriate behaviors towards staff and a female peer over several days. Nursing and behavior notes detailed repeated incidents of the resident exposing himself, masturbating in common areas, and making unwanted advances toward staff, which were reported to the medical provider and Director of Nursing. Despite these ongoing behaviors, the resident was able to enter another resident's room and inappropriately touch and kiss her, including attempts to remove her clothing and touch her private areas. The female resident, who had a history of stroke, physical debility, and moderate cognitive impairment, was found by staff in distress, attempting to push the male resident away while he was touching her. Staff intervened and removed the male resident from the room, but observations after the incident revealed that one-on-one supervision was not consistently maintained as required. Interviews with staff confirmed that the male resident was not being properly supervised at all times, even after the incident, and that the female resident was visibly upset and crying following the assault. The facility's abuse policy prohibits any form of abuse, including sexual abuse, and requires an environment free from such incidents. The failure to provide adequate supervision and prevent the male resident's access to the female resident resulted in a violation of residents' rights to be free from abuse.
Failure to Document Thorough Abuse Investigation
Penalty
Summary
The facility failed to maintain evidence that an allegation of abuse was thoroughly investigated for two residents. One resident, who had a history of stroke, physical debility, and moderate cognitive impairment, reported that another resident, who was cognitively intact and independent in mobility, entered her room without permission and attempted to touch and kiss her inappropriately. The incident was witnessed by three CNAs, who intervened and removed the alleged perpetrator from the room. The reporting nurse, Weekend Supervisor (WS) 8, documented the incident in the residents' medical records and notified the Executive Director, Director of Nursing, and the police department. Both residents were placed on one-on-one supervision following the incident. Despite these actions, the facility's investigation file for the incident did not include a written statement from WS 8, who was the staff member in charge and had direct knowledge of the event. The Corporate Executive Director confirmed that while WS 8 had made progress notes in the medical records, there was no separate written statement included in the investigation file. The facility's abuse policy requires that statements be taken from individuals witnessing the incident and from the staff member to whom the initial report was made, but this documentation was missing from the investigation file.
Failure to Timely Refer Residents for PASRR Assessment After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to timely refer residents with new psychiatric diagnoses for appropriate Level 1 or Level 2 Preadmission Screening and Resident Review (PASRR) assessments. In one case, a resident with a history of dementia was newly diagnosed with schizoaffective disorder, and the clinical record showed that after the diagnosis and initiation of antipsychotic medication, there was no documentation of a Level 1 or Level 2 PASRR review being completed. The diagnosis was later included in a subsequent MDS assessment, but the referral for a Level 2 review was not made until several months after the diagnosis. In another instance, a resident with a new diagnosis of borderline personality disorder and subsequent initiation of Depakote did not have a new Level 1 PASRR screening completed following the diagnosis. The Social Services Director acknowledged that the screening had not been done and was unsure of the required timeframe for completion. The facility's policy required PASRR assessments to be updated with significant changes in mental or physical status, but this was not followed in these cases.
Failure to Provide Timely ADL Assistance and Scheduled Showers
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs) for two residents. One resident with chronic respiratory failure and hemiplegia, who required substantial assistance to reposition in bed, repeatedly requested to be pulled up in bed during medication administration. Despite making multiple requests to staff, including a Qualified Medication Aide (QMA) and the presence of two Certified Nurse Aides (CNAs), the resident was not assisted in a timely manner. The QMA indicated that the CNA was busy and would assist when available, but the resident remained unassisted for an extended period, as confirmed by subsequent observation and resident interview. Another resident with a history of stroke and who was cognitively intact did not consistently receive scheduled showers as outlined in her care plan, which specified showers twice weekly with partial bed baths in between. Documentation and resident interviews confirmed missed showers on scheduled days, and the Director of Nursing acknowledged the expectation for regular showers and partial baths, but there was no formal policy on ADL care. These failures were identified through observation, record review, and interviews with residents and staff.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to administer medications and treatments as ordered for multiple residents. One resident with a history of liver transplant and major depressive disorder did not receive several doses of their prescribed immunosuppressive medication, mycophenolate mofetil, on multiple occasions because the medication was unavailable. The resident, who was cognitively intact, expressed concern about missing these doses. The physician confirmed that missing scheduled doses of this medication was not good practice. Another resident with a history of stroke, major depressive disorder, and physical debility did not receive prescribed doses of aspart insulin on several occasions, with no documented reason or evidence that the medical provider was informed of the missed doses. The insulin order did not include parameters to hold the medication, yet it was not administered at times when blood sugar readings were recorded, and on other occasions, there was no documentation at all. Additionally, a resident with chronic respiratory failure and hemiplegia was observed during incontinent care requesting rectal cream for burning. The CNA applied Preparation H rectal cream, which was not within their scope of practice according to facility leadership. The resident's orders required staff to apply the cream and monitor vital signs, but the application was performed by a CNA rather than a licensed nurse. The DON confirmed that the CNA should not have been applying the rectal cream.
Failure to Provide Oxygen Therapy as Ordered
Penalty
Summary
A resident with chronic respiratory failure and hemiplegia had a physician's order to receive two liters of oxygen via nasal cannula every shift. During a medication administration, the resident was observed with the nasal cannula out of her nose and lying on her chest, not receiving oxygen as ordered. The Qualified Medication Aide (QMA) educated the resident and assisted with replacing the nasal cannula in her nose. However, the oxygen concentrator was set to five liters instead of the ordered two liters. The QMA recognized the discrepancy but was unable to adjust the oxygen level and indicated she would notify the nurse, yet there was no observation of her reporting the issue before leaving to continue other tasks. Later, the resident was again observed with the nasal cannula in place, but the oxygen concentrator remained set at five liters. After reviewing the order, the nurse consultant confirmed the resident should be on two liters and adjusted the setting accordingly. The facility's oxygen therapy procedure required verification of the resident and physician order, which was not followed at the time of the initial observation.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents who required pain medication. One resident with diabetes mellitus, who was cognitively intact, requested Tylenol for pain at 3:00 p.m. but did not receive it until over five hours later, after intervention by a nurse consultant. The responsible LPN admitted to not having reached the resident's medication pass and was observed preparing medication for another resident instead. The nurse consultant confirmed that pain medication should be administered shortly after it is requested. Another resident, also cognitively intact and diagnosed with cellulitis and other chronic conditions, reported experiencing significant delays in receiving prescribed hydrocodone for pain. The resident described waiting between 30 minutes to an hour for pain medication after making requests, and on one occasion, had to ask multiple staff members for assistance before the LPN addressed her pain. The LPN acknowledged being informed of the request by CNAs but was observed administering medications to other residents before attending to the resident's pain needs.
Failure to Document and Update Care Plan for Resident with Dementia-Related Behaviors
Penalty
Summary
The facility failed to timely document and update the care plan with new interventions for a resident diagnosed with dementia who exhibited wandering and inappropriate urination behaviors. The resident, who had severe cognitive impairment due to Alzheimer's disease and was occasionally incontinent, was noted to have entered another resident's room and used their bed, which caused distress to the other resident. Although staff were aware of the resident's wandering and incontinence, and interventions such as redirection and routine toileting were in place, there was no documentation of the specific incident in the clinical record, nor were new interventions, such as the use of stop signs on doors, implemented or added to the care plan. Interviews with staff revealed that the resident's behaviors, including wandering into other residents' rooms and using their beds or bathrooms, were known issues. The Weekend Supervisor had suggested using stop signs as a deterrent, but this intervention was not communicated to or recalled by the DON, and no stop signs were observed in the facility. The Social Service Director confirmed that no new interventions had been attempted to help the resident better identify his own room, and that behavior documentation and review processes were inconsistently followed. The facility's behavior management policy required that new or worsening behaviors be documented and reviewed by the interdisciplinary team, with care plans updated as needed. However, the incident involving the resident entering another's room and the associated behaviors were not documented in the clinical record, and the care plan was not updated with new interventions. This lack of timely documentation and failure to initiate or implement new interventions contributed to the deficiency cited during the survey.
Failure to Follow Up on Pharmacy Recommendations and Medication Management
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely follow-up on pharmacy recommendations for a resident reviewed for unnecessary medications. The resident, who had a history of stroke and was cognitively intact, had a pharmacy recommendation to discontinue fenofibrate and obtain a fasting lipid panel four weeks after discontinuation. Although the physician agreed with the recommendation and ordered the lab, the facility was unable to provide evidence that the lipid panel was completed as ordered. Additionally, the same resident was prescribed prophylactic antibiotics for urinary tract infection prevention. The pharmacy recommended discontinuing both nitrofurantoin and trimethoprim or documenting the intended duration of therapy. The physician referred the case to urology, but the resident did not attend the follow-up appointment, and there was no documentation of urology consultation regarding the continued use of antibiotics. The Director of Nursing was unable to explain the rationale for the resident being on two prophylactic antibiotics simultaneously.
Insulin Vials Missing Open/Expiration Dates on Medication Cart
Penalty
Summary
Surveyors identified that the facility failed to ensure insulin medications were properly labeled with open and/or expiration dates on one of three medication carts observed. Specifically, insulin vials for three residents with diabetes mellitus—prescribed Novolin, Humalog, and lispro insulin—were found without written open or expiration dates during a medication cart observation. The absence of these dates was confirmed during an interview with a registered nurse, who acknowledged that insulin medications should have open dates. The facility's own medication storage policy, provided by the Executive Director, requires that medications have expiration dates on their labels. Despite this policy, the insulin vials for the affected residents did not comply with labeling requirements at the time of the survey. The deficiency was based on direct observation, record review, and staff interview, and involved residents with active physician orders for insulin administration due to their diabetes diagnoses.
Failure to Maintain Infection Control During Medication Administration and Resident Care
Penalty
Summary
Staff failed to maintain proper infection control practices during medication administration and resident care. In two separate instances, a Qualified Medication Aide (QMA) was observed administering eye drop medications to residents without performing hand hygiene beforehand. The QMA handled various items such as medication cards, water cups, and the medication cart before entering the residents' rooms and administering both oral and eye drop medications, but did not wash or sanitize her hands prior to these tasks. The QMA herself indicated uncertainty about glove use for eye medications but acknowledged the need for hand hygiene. The Director of Nursing confirmed that hand hygiene should be performed before administering eye drops. In another case, a resident with multiple diagnoses, including HIV, hepatitis B, Crohn's disease, and a colostomy, was observed keeping open containers of urine and feces on his bedside table, along with a urinal and food items nearby. The resident preferred to keep these containers to monitor his output, and staff had documented his refusal to allow removal or cleaning of the bedside table. Despite education and encouragement from staff to use appropriate disposal methods, the containers remained on the bedside table. The resident was under Enhanced Barrier Precautions due to risk factors such as an indwelling device and chronic wound. When a nurse consultant was notified about the presence of bodily fluids on the bedside table, she entered the resident's room, performed hand hygiene, donned gloves, and removed one of the containers, but did not wear a gown as required by the facility's Enhanced Barrier Precautions policy. Facility policies provided to surveyors specified the need for hand hygiene before and after resident contact and the use of gowns and gloves during high-contact care activities for residents under Enhanced Barrier Precautions.
Failure to Maintain a Homelike Environment Due to Unrepaired Room Conditions
Penalty
Summary
The facility failed to promote a homelike environment for three of five residents reviewed for environmental concerns. Observations revealed that two residents had broken blinds in their rooms, and one resident's room had a strong urine odor and an area of scraped paint on the wall behind the bed. One resident reported that the broken blinds had been an issue for three years and that it bothered him, especially when he had visitors. During a walk-through with the Maintenance Supervisor and Housekeeping Supervisor, these issues were confirmed, including the persistent urine odor and damaged paint. The Maintenance Supervisor acknowledged awareness of the broken blinds and scraped paint, stating that repairs were pending due to budget constraints and the need to obtain the correct paint color. He was unable to provide documentation or work orders for these repairs. The Housekeeping Supervisor indicated that staff cleaned and mopped the room with the urine odor daily and used an odor eliminator, but believed the mattress was the source of the smell and needed replacement. The facility did not have a specific policy addressing a homelike environment, though a general resident rights policy was in place.
Failure to Serve Breakfast at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to serve breakfast at safe and palatable temperatures, affecting 54 of 55 residents. During a Resident Council meeting, 8 of 10 residents indicated that breakfast was often served cold. Resident 43 and Resident B also reported that breakfast was frequently served cold. Observations in the facility kitchen revealed that plates of fried and scrambled eggs were left sitting on the counter and shelf, with temperatures measured at 100 degrees Fahrenheit and 86 degrees Fahrenheit, respectively. Sausage patties on the steam table were measured at 109 degrees Fahrenheit. The Dietary Manager indicated that the food should be microwaved or reheated before serving, but this was not consistently done. Further observations showed that a breakfast tray delivered by the Infection Preventionist Float contained food items with temperatures below the required 135 degrees Fahrenheit. The sausage patty was measured at 129.3 degrees Fahrenheit, and the oatmeal at 130.5 degrees Fahrenheit. The facility's Food Temperatures Policy, last revised in June 2023, mandates that hot foods be held for service at or above 135 degrees Fahrenheit and served at a palatable temperature. The facility's failure to adhere to this policy resulted in the deficiency.
Facility Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the first-floor shower room in good condition and did not timely repair a leaking pipe for the pot filler in the kitchen, potentially affecting all 55 residents. On 4/16/24, a leaking pipe in the kitchen was observed with a clear pasty substance at the joints and rusted joint clamps, with a puddle of water underneath. The Dietary Manager indicated that a work order had been submitted, and the Registered Dietician noted that the pipe had been leaking for a while. A service request dated 4/16/24 confirmed the need for repair. On 4/17/24, a resident reported that the first-floor shower room was often dirty and smelled of urine. An observation on 4/22/24 revealed a dingy tile floor with dirt, soiled linen bags on the floor, and stained tiles around the shower drain. The Executive Director and Maintenance Supervisor confirmed the stained and dirty condition of the shower room floor. The Executive Director acknowledged the stained appearance of the shower room floor.
Failure to Provide Timely Assistance with Dressing
Penalty
Summary
The facility failed to timely provide assistance with dressing for a resident diagnosed with dementia and heart failure. The resident's care plan, initiated in June 2020, indicated that he required assistance with activities of daily living (ADL) due to his conditions. Despite this, observations over several days revealed that the resident was wearing the same clothing, which was ill-fitting and improperly worn. The resident was seen in the same brown t-shirt and purplish sweatpants with a binder clip attached to the waistband, which was around his thighs instead of his waist. The resident indicated that the sweatpants were too big for him. Interviews with staff confirmed that the resident would change his clothing if approached correctly, yet he continued to wear the same clothes over multiple days. A CNA acknowledged that the resident was wearing the same clothing as the previous day and stated that she would assist him in changing his clothing. The facility's failure to provide timely assistance with dressing for the resident was evident through these observations and interviews.
Failure to Administer Medications and Monitor Conditions
Penalty
Summary
The facility failed to properly assess and manage the care of Resident B, who had multiple medical conditions including type 2 diabetes mellitus, borderline personality disorder, and bipolar disorder. The resident did not receive her prescribed lispro insulin on several occasions, specifically on 4/4/24, 4/5/24, 4/11/24, and 4/12/24. Additionally, there was confusion regarding the dosage and administration times of her antipsychotic medication, Seroquel, which was not clarified in a timely manner. Furthermore, the resident had an open area on her umbilicus that required cleansing twice a day, but there were no assessments documented for this skin condition until 4/17/24, despite the order being placed on 4/3/24. Resident 27, who had diagnoses including constipation, heart failure, and chronic kidney disease, also experienced deficiencies in care. The resident's care plan indicated the need for monitoring bowel movements and administering medications as ordered to prevent constipation. However, the bowel movement records showed multiple days without a bowel movement, and there was no documentation of the administration of prescribed Dulcolax or Milk of Magnesia. The facility's policy required bowel movements to be recorded daily and for interventions to be taken if no bowel movement occurred for three consecutive days, which was not followed. These deficiencies highlight significant lapses in the facility's adherence to care plans, medication administration, and monitoring protocols. The Director of Nursing Services and other staff members were unable to provide explanations for these lapses, indicating a lack of oversight and communication within the facility. The failure to follow established policies and physician orders resulted in inadequate care for the residents involved.
Failure to Provide Oral and G-Tube Site Care
Penalty
Summary
The facility failed to provide oral care as ordered by the physician and did not timely obtain a physician's order for gastrostomy tube site care for Resident 23. Resident 23, diagnosed with dysphagia, aphasia, and gastrostomy, had a care plan initiated in 2018 to prevent complications related to enteral feedings. Despite a physician's order from 2021 to provide oral care every shift, observations on 4/16/24 and 4/18/24 revealed that Resident 23 had dried brown drainage at the base of his g-tube and a white film on his teeth and lips, indicating a lack of proper oral and g-tube site care. Interviews with Resident 23 and LPN 3 confirmed that oral care and g-tube site care were not consistently provided as required. The Director of Nursing Services (DNS) acknowledged the absence of a physician's order for g-tube site care in the medical record and confirmed that oral care should be performed as ordered. The facility's Enteral Tube Skills Competency guidelines, last reviewed in 2019, stated that dressing or site care of the enteral tube should be done at least daily, which was not adhered to in this case.
Inadequate Monitoring and Documentation of Resident Behaviors
Penalty
Summary
The facility failed to adequately monitor and document behaviors for Resident 45, who had a history of schizoaffective disorder, bipolar disorder, and other cognitive impairments. Despite multiple incidents of inappropriate sexual behavior towards staff and other residents, the facility's interventions were insufficient and not effectively documented. For instance, after Resident 45 inappropriately touched a female staff member on 1/14/24, the only intervention was to explain the inappropriateness of the behavior and redirect him. This intervention proved somewhat effective but did not prevent further incidents. The care plan did not address the potential for inappropriate behavior towards other residents, and subsequent incidents, including one on 2/24/24 where Resident 45 touched another resident's breast, were not adequately addressed with effective interventions or proper documentation. Resident 45's behavior continued to be problematic, with multiple reports of him entering other residents' rooms uninvited and making inappropriate comments and gestures. Despite these ongoing issues, there were no care plans to address his wandering into other residents' rooms or his inappropriate sexual behavior towards residents. The facility's documentation was also lacking, as there were no progress notes or events in the electronic health record referencing the frequent occurrences of Resident 45 going into other residents' rooms uninvited. The Social Services Director acknowledged that the care in pairs intervention, which was eventually put in place, should have been implemented after the first incident in January. Similarly, the facility failed to document and monitor the behaviors of Resident 38, who had a diagnosis of schizophrenia and exhibited episodes of verbal aggression and irritability. Despite a care plan that included interventions such as encouraging activities and redirecting the resident to a calmer space, there were significant gaps in the documentation of his behaviors. For example, an incident on 4/16/24 where Resident 38 became upset and left a resident council meeting while cussing loudly was not documented in his clinical record. The facility's behavior management policy was not followed, as staff did not consistently report and document the resident's behaviors, leading to inadequate monitoring and management of his condition.
Medication Error Rate Exceeds 5 Percent
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5 percent, resulting in a 5.88% error rate during a medication pass observation. Specifically, for Resident 43, who has a diagnosis of type 2 diabetes mellitus, the staff did not follow proper procedures for blood sugar monitoring and insulin administration. The resident's blood sugar was checked after she had already started eating her breakfast, contrary to the physician's order to obtain blood sugars four times a day at specific times. Additionally, the LPN did not prime the lantus flex pen before administering the insulin, which is against the manufacturer's instructions. Interviews with the LPN and the Director of Nursing Services confirmed that the blood sugars should be obtained before meals and that the insulin flex pens should be primed before use. Resident 43 also indicated that staff frequently check her blood sugar after she eats her meals. These actions and inactions led to the observed medication errors, contributing to the facility's failure to maintain a medication error rate below the required threshold.
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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