Core Of Dale
Inspection history, citations, penalties and survey trends for this long-term care facility in Dale, Indiana.
- Location
- 510 W Medcalf Road, Dale, Indiana 47523
- CMS Provider Number
- 155270
- Inspections on file
- 40
- Latest survey
- September 25, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Core Of Dale during CMS and state inspections, most recent first.
The facility did not ensure that the Dietary Manager held the required certification for the position, as confirmed by interviews and review of job descriptions specifying certification as a minimum qualification.
Staff lacked knowledge and failed to properly test the chemical sanitizer levels in the facility's low-temperature dishwasher, resulting in chlorine levels well below the required range. The issue was identified when the Maintenance Supervisor used a test strip and found only 10 ppm chlorine, despite the facility's policy requiring 50-100 ppm.
Care plans for several residents with a history of sexual offenses were not revised to include individualized behaviors, restrictions, or interventions. Instead, only general interventions were listed, and staff were not consistently informed of specific restrictions or offender status. This resulted in a lack of resident-specific care planning and communication regarding the management of sexual offenders in the facility.
Surveyors identified strong urine odors in several rooms and shared bathrooms, soiled call light cords, and loose grab bars and toilet seats. Incontinence care products were found stored in a resident's refrigerator with food items. Housekeeping staff noted ongoing odor issues related to improper toilet flushing, and the DON reported no specific environmental policy in place.
A resident with dementia and significant weight loss did not have monthly weights properly recorded in the clinical record, and the medical provider was not notified of the weight loss. The dietitian's recommendation to increase a nutritional supplement was not implemented, and the resident continued to receive the supplement only once daily. The lack of documentation and communication among staff resulted in missed interventions to address the resident's ongoing weight loss.
A CNA took a resident's debit card without consent and withdrew $305.00 from the resident's bank account, failing to follow facility policy requiring administrative approval and documentation for such transactions. The resident, who had no cognitive impairment, did not authorize the withdrawal or receive the funds, and the incident was confirmed by video evidence.
A resident with a history of behavioral issues was involved in an incident where a CNA retaliated after being hit by the resident during care. The resident reported feeling the CNA was too rough and was threatened with retaliation. The facility's investigation found that the CNA did not follow proper protocol for handling aggressive behavior, leading to a deficiency in protecting the resident from abuse.
The facility failed to supervise two cognitively impaired residents, leading to their elopement. One resident exited through a malfunctioning side door and walked to a gas station, while another left through a faulty front door. Both residents had histories of wandering, but their care plans were not updated. Additionally, the facility did not implement fall risk interventions for two residents, resulting in multiple falls without care plan updates or proper notifications.
The facility failed to provide required transfer or discharge notices to residents or their representatives during hospitalizations. This deficiency was identified for five residents, including those with Parkinson's, dementia, and stroke. The DON confirmed the lack of documentation for these transfers, indicating a systemic issue.
The facility failed to provide a bed hold policy to residents or their representatives during hospital transfers, affecting five residents. Despite the facility's policy requiring a written reservation agreement, documentation was missing for residents with various medical conditions, including Parkinson's disease, dementia, and stroke. The DON confirmed the absence of necessary documentation for these cases.
The facility failed to follow infection control practices during incontinence and wound care for several residents. Staff did not sanitize hands or change gloves between tasks, and handwashing was not performed for the required duration. The Infection Preventionist did not use an infection assessment tool, relying on nursing judgment instead. Facility policies on hand hygiene and infection control were not followed.
A facility failed to update a resident's code status, resulting in a mismatch between the resident's signed DNR form and the physician's orders indicating full code status. The resident, who was cognitively intact, expressed a desire to be a DNR, but staff were unaware of this preference. The DON confirmed the resident should be a DNR and highlighted the responsibility of nursing staff to update code status promptly.
The facility failed to ensure accurate MDS Assessments for three residents, leading to omissions and misclassifications of critical medical information. A resident's history of CVA was not marked, another's antiplatelet use was incorrectly coded as an anticoagulant, and a third resident's TBI was not included as an active diagnosis. The MDS Coordinator acknowledged these errors, and it was noted that the facility lacked a specific policy for MDS Assessments.
The facility failed to create care plans for three residents receiving antiplatelet medications. A resident with rheumatoid arthritis and atrial fibrillation, another with peripheral vascular disease, and a third with a traumatic brain injury were all prescribed antiplatelets without documented care plans. The MDS Coordinator admitted to the oversight, typically including antiplatelets with anticoagulant plans, but did not do so for these residents.
The facility failed to update care plans and physician orders for two residents, leading to deficiencies in care. A resident's care plan for a respiratory illness was not removed after recovery, and a pre-op diet order was not rescinded post-procedure. Another resident's care plans for antianxiety and anticoagulant medications remained active despite discontinuation of the medications. The DON acknowledged these oversights, which were contrary to the facility's policy on care plan revisions upon status change.
The facility failed to adequately track and assess behaviors for two residents at risk for behavioral issues. For one resident, the behavior tracking system was inconsistent, with missing documentation for behaviors like wandering and insomnia. The SSD acknowledged the lack of a comprehensive tracking system, and the RN was unaware of the resident's insomnia. For another resident, discrepancies existed in behavior documentation across the MAR, progress notes, and task records. The facility's policy required behavior monitoring every shift, but documentation did not align with this policy.
The facility failed to maintain accurate documentation for two residents. One resident's records inaccurately showed them as present in the facility during hospitalization, with incorrect activity and medication monitoring entries. Another resident's fall risk assessments were inconsistent, failing to reflect their history of falls and predisposing conditions. The DON acknowledged errors in documentation and the need for consistent protocol adherence.
The facility failed to provide necessary treatment and services for residents with dementia, leading to multiple incidents of aggressive and inappropriate behavior. Care plans were not updated, recommended treatments were not followed, and residents were left unsupervised, resulting in physical altercations and sexually inappropriate conduct.
The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident. The investigation did not include interviews with all potential witnesses or other residents who received care from the accused CNA, contrary to the facility's policy on abuse investigation.
Dietary Manager Lacked Required Certification
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, as required. The Dietary Manager, who began in the role on 9/5/25, did not possess a current certification at the time of the survey and was in the process of becoming re-certified. During an interview, the Dietary Manager confirmed the lack of current certification. The Director of Nursing provided a job description for the Dietary Manager position, which specified that certification as a dietary manager or food service manager is a minimum requirement, along with meeting state requirements. The deficiency was identified through interviews and record review, with no mention of specific residents or patient conditions.
Failure to Properly Test Dishwasher Sanitizer Levels
Penalty
Summary
The facility failed to properly test and monitor the dishwasher's sanitation process, as staff were not knowledgeable about the correct use of chlorine test strips required for a low-temperature dishwasher. The Dietary Manager was unsure of the dishwasher type and reported that staff only checked the temperature, not the chemical sanitizing levels, and could not locate the necessary test strips. Maintenance staff confirmed that while they checked the temperature daily, they did not test the chemical levels, as this was not their responsibility. When the Maintenance Supervisor eventually tested the dishwasher with a chlorine strip, the reading was 10 ppm, which was below the required 50-100 ppm as stated in the facility's manual. The DON indicated that kitchen staff were expected to notify maintenance of any issues, but they were unaware of the problem until it was discovered during the survey. No specific residents or patient conditions were mentioned in relation to this deficiency.
Failure to Revise Care Plans for Residents with Sexual Offender Status
Penalty
Summary
The facility failed to ensure that care plans for residents with a history of sexual offenses were specific, comprehensive, and revised to include individualized behaviors, restrictions, and interventions. Four residents with sexual offender status were reviewed, and in each case, their care plans lacked detailed information about their specific sexual offender history, the nature of their offenses, and any individualized restrictions or interventions required. The care plans contained only general interventions such as monitoring for inappropriate sexual behaviors, involving residents in activities, and encouraging appropriate communication, without addressing resident-specific risks or restrictions. For example, one resident with moderate cognitive impairment and a history of multiple sclerosis was listed as a sex offender, but their care plan did not specify their offense or any unique restrictions. Another resident, identified as a sexually violent predator and cognitively intact, had a care plan that did not include details about their specific behaviors or restrictions, despite a history of verbal aggression and medication refusal. A third resident with psychoactive substance abuse and a history of noncompliance had a care plan focused on physical aggression, with no mention of their sexual offender status or related restrictions. A fourth resident, who was later discharged for parole violations involving prohibited electronic devices and inappropriate images, also had a care plan lacking individualized details about their sexual offender history and restrictions. Interviews with facility staff revealed a lack of clear communication and documentation regarding which residents were sexual offenders and what specific restrictions applied to them. Staff often learned about residents' offender status informally, and restrictions were not consistently incorporated into care plans or communicated to all staff. The facility's policies required care plan revisions and safety plans for offenders, but these were not effectively implemented, resulting in care plans that did not address the unique needs and risks associated with residents who were sexual offenders.
Environmental Deficiencies: Odors, Soiled Equipment, and Unsafe Fixtures
Penalty
Summary
The facility failed to maintain a homelike and safe environment for residents, as evidenced by strong urine odors in multiple resident rooms and shared bathrooms, soiled call light cords, and loose grab bars and toilet seats. Observations on two separate dates revealed persistent strong urine odors in several rooms and bathrooms, with no improvement noted between visits. Additionally, call light cords in several bathrooms were found to be brown and soiled, with some cords wrapped around grab bars, and grab bars and toilet seats were reported as loose. Further deficiencies were identified when peri-cleanser and cream, both used for incontinence care, were found stored in a resident's refrigerator alongside food items. A CNA confirmed that these items should not be stored in the refrigerator and removed them. Housekeeping staff acknowledged that some rooms had persistent odors due to residents not flushing toilets properly and stated that they used odor eliminators and cleaned rooms daily. The DON indicated there was no specific policy for maintaining the environment, but that regulations were followed.
Failure to Monitor and Address Resident Weight Loss and Nutrition Orders
Penalty
Summary
The facility failed to ensure that services provided met professional standards for a resident with significant nutritional needs. A resident with dementia, dependent on staff for eating and other activities of daily living, experienced ongoing weight loss. The resident was on a mechanical soft diet and had orders for monthly weights and a daily nutritional supplement (magic cup). However, the resident's weights for August and September were not entered into the clinical record, and there was no documentation that the medical provider or family were notified of the weight loss. The dietitian's recommendation to increase the supplement to twice daily was not implemented, and the resident continued to receive the supplement only once daily with supper. Interviews and record reviews revealed that the registered dietitian had not evaluated the resident since July, and the dietary manager was unaware of current residents with weight loss. The process for monitoring and reporting weight changes was not followed, as weights were not consistently recorded or communicated to the appropriate staff. The lack of documentation and communication led to missed interventions, including the failure to increase nutritional supplementation and notify the medical provider of significant weight loss, as required by facility policy.
Unauthorized Withdrawal of Resident Funds by Staff
Penalty
Summary
A certified nursing assistant (CNA) took a resident's debit card without consent and used it to withdraw $305.00 from the resident's bank account. The incident occurred in the early morning hours, and the resident was alerted to the unauthorized withdrawal by a notification from his bank. The resident, who had diagnoses including heart failure, COPD, and chronic pain, was assessed as having no cognitive impairment at the time of the incident. During interviews, the resident stated that he did not give the CNA his debit card or ask her to withdraw money, nor did he receive any of the withdrawn funds. Facility policy required that any staff member taking a resident's debit card for transactions must have approval from the Administrator or DON, especially after hours, and that a Money Transaction Shopping Form must be completed. Staff interviews confirmed that the proper procedures were not followed, as there was no documentation or approval for the transaction, and the whereabouts of the withdrawn cash remained unknown. Video evidence from the local ATM corroborated that the CNA made the withdrawal without proper authorization.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nurse Aide (CNA) and a resident. The incident occurred when the resident, who has a history of behavioral issues due to multiple diagnoses including traumatic brain injury and schizoaffective disorder, became agitated during incontinence care. The resident allegedly hit the CNA in the face, and in retaliation, the CNA struck the resident in the ribs. The resident later reported feeling that the CNA was being too rough during care and claimed that the CNA threatened to hit back if struck. The facility's investigation revealed that the CNA did not follow proper protocol when dealing with aggressive behavior from the resident. According to another CNA, staff members are instructed to remove themselves from situations where a resident is being aggressive and to re-approach the resident later. The facility's policy emphasizes the prohibition of abuse, including physical and verbal threats, but this protocol was not adhered to in this instance, leading to the deficiency.
Inadequate Supervision and Elopement Policy Failures
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to its elopement policy, resulting in two cognitively impaired residents eloping from the facility. Resident B, who had a history of wandering and was wearing a WanderGuard, exited the facility through a side door that was not properly secured due to a malfunctioning alarm system. The resident walked 0.5 miles to a gas station before being picked up by staff. The facility's records did not document any exit-seeking behavior prior to the incident, and the care plan was not updated with new interventions to prevent further elopement. Resident C, who was moderately cognitively impaired and also wore a WanderGuard, exited the facility through the front door after returning from an overnight stay with family. The front door was found to be malfunctioning, and the alarm did not sound as expected. The resident was found outside the facility by a staff member and returned safely. Despite previous notes indicating wandering behavior, the care plan was not updated after the elopement incident. Additionally, the facility failed to implement interventions to reduce fall risks for two residents. Resident 18 experienced multiple falls without updates to the care plan or proper notifications to family and physicians. Similarly, Resident 33 had falls without documented post-fall risk assessments or care plan updates. The facility's failure to complete fall risk assessments and update care plans after falls contributed to ongoing safety risks for these residents.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide timely notification of transfer or discharge to residents or their representatives, as required by regulations. This deficiency was identified for five residents who were hospitalized. The clinical records for these residents lacked documentation of a notice of transfer or discharge being given at the time of hospitalization. Specifically, Resident 12, diagnosed with Parkinson's disease and dementia, was transferred to the hospital without receiving the necessary notice. Similarly, Resident 33, with a history of stroke and dementia, was also transferred without proper notification. Further instances of this deficiency were noted with Resident 18, who was hospitalized on multiple occasions, and Resident 6, who was transferred to the hospital without receiving the required notice. Additionally, Resident 7's records did not contain documentation of a transfer notice during their hospitalization. Interviews with the Director of Nursing confirmed the absence of documentation for these transfers, indicating a systemic issue in the facility's process for notifying residents and their representatives of transfers or discharges.
Failure to Provide Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold policy to residents or their representatives during hospital transfers, as required. This deficiency was identified for five residents who were hospitalized. Resident 12, diagnosed with Parkinson's disease and dementia, was transferred to the hospital and returned without documentation of receiving a bed hold policy. Similarly, Resident 33, with a history of stroke and dementia, was also transferred and returned without the necessary documentation. The Director of Nursing (DON) confirmed the absence of documentation for both residents. Further review revealed that Resident 18, who was hospitalized on multiple occasions, did not receive a bed hold policy during any of these transfers. Resident 6, hospitalized on a specific date, also lacked documentation of receiving the policy. Additionally, Resident 7's records did not show that a bed hold policy was provided during their hospitalization. The DON acknowledged the lack of documentation for these residents, despite the facility's policy requiring a written reservation agreement prior to discharge or as soon as possible in emergency situations.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to ensure proper infection control practices during incontinence and wound care for several residents. During a dressing change for a resident, a registered nurse did not wash or sanitize hands before putting on gloves, failed to change gloves between tasks, and did not sanitize hands after removing gloves. The nurse also did not lather for the recommended 20 seconds when washing hands. This lack of proper hand hygiene and glove use was observed during the care of Resident 35. Incontinence care for multiple residents was also performed without adherence to infection control protocols. Certified Nurse Aides (CNAs) were observed not sanitizing hands before donning gloves, failing to change gloves between dirty and clean tasks, and not washing hands for the required duration. For instance, during care for Resident 2, CNAs used the same gloves throughout the process, including when handling clean items, and did not offer the resident an opportunity to wash hands afterward. Similar lapses were noted in the care of Residents 12, 15, and 31, where CNAs did not change gloves or perform hand hygiene between tasks. The facility's Infection Preventionist admitted to not using an infection assessment tool or management algorithm, relying instead on nursing judgment. The facility's policies on hand hygiene, perineal care, and infection control were not followed, as evidenced by the observations. These policies require hand hygiene before and after glove use, changing gloves between tasks, and ensuring residents' hands are cleaned during care. The Infection Preventionist provided these policies during the survey, but they were undated and not adhered to by the staff.
Failure to Clarify Resident's Code Status
Penalty
Summary
The facility failed to clarify a resident's code status, leading to a discrepancy between the resident's wishes and the documented orders. Resident 41, who was cognitively intact and diagnosed with conditions including hypertension and hyperlipidemia, had a signed Do Not Resuscitate (DNR) form. However, the current physician's orders and care plans indicated a full code status, meaning CPR would be performed. During interviews, Resident 41 expressed a desire to be a DNR, but RN 25 stated that the resident was a full code. The Director of Nursing acknowledged that Resident 41 should be a DNR and emphasized that nursing staff are responsible for updating code status immediately when changes occur. The facility's Advance Directive Policy, provided by the DON, underscored the importance of respecting residents' healthcare choices, yet the policy was undated.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) Assessments for three residents, leading to deficiencies in documenting critical medical information. For Resident 5, the MDS Assessment did not mark a history of cerebrovascular accident (CVA) despite it being a part of the resident's diagnosis. This oversight was acknowledged by the MDS Coordinator as an error. Similarly, Resident 14's MDS Assessment incorrectly coded the use of Clopidogrel, an antiplatelet medication, as an anticoagulant, despite the absence of any anticoagulant orders or administration during the assessment period. This misclassification was also confirmed by the MDS Coordinator. Resident B's MDS Assessment failed to include traumatic brain injury (TBI) as an active diagnosis, despite it being part of the resident's medical history. The MDS Coordinator admitted that TBI should have been included but was missed. Additionally, it was noted that the facility did not have a specific policy for conducting MDS Assessments, relying instead on the Resident Assessment Instrument (RAI) manual. These inaccuracies in the MDS Assessments highlight a lack of attention to detail in documenting residents' medical conditions accurately.
Failure to Develop Care Plans for Antiplatelet Use
Penalty
Summary
The facility failed to develop a care plan for three residents who were receiving antiplatelet medications. Resident C, diagnosed with conditions including rheumatoid arthritis, paroxysmal atrial fibrillation, and dementia, was prescribed aspirin for atrial fibrillation but lacked a care plan for its use. Similarly, Resident 3, with peripheral vascular disease and cognitive impairment, was on a daily aspirin regimen without an accompanying care plan. Resident 10, who had a traumatic brain injury and moderate cognitive impairment, was prescribed clopidogrel for stroke prevention, yet no care plan was documented for the antiplatelet medication. During an interview, the MDS Coordinator acknowledged the omission, stating that she typically included antiplatelet medications with anticoagulant care plans but had not done so for these residents. The facility's policy mandates the development of a comprehensive, person-centered care plan for each resident, which was not adhered to in these cases. The Director of Nursing provided a policy document confirming this requirement, highlighting the oversight in care planning for the residents involved.
Failure to Update Care Plans and Physician Orders
Penalty
Summary
The facility failed to update care plans and physician orders to reflect the current status of residents, leading to deficiencies in care for two residents. Resident 14, diagnosed with dementia and depression, had a care plan for a respiratory illness that was not removed after recovery. Additionally, a pre-operative diet order was not rescinded after the procedure, resulting in an unnecessary dietary restriction. The Director of Nursing acknowledged that the restrictive diet order should have had an end date and that the care plan for the respiratory illness should have been resolved. Resident 10, with diagnoses including traumatic brain injury, anxiety, and depression, had care plans for antianxiety and anticoagulant medications that were not updated after the medications were discontinued. The clinical record lacked current orders for these medications, yet the care plans remained active. The Director of Nursing confirmed that the care plans should have been removed following the discontinuation of the medications. The facility's policy on care plan revisions upon status change was not adhered to, contributing to these deficiencies.
Inadequate Behavior Tracking for Residents
Penalty
Summary
The facility failed to ensure the safety of residents by inadequately tracking and assessing behaviors for two residents, Resident B and Resident 4, who were at risk for behavioral issues. For Resident B, the behavior tracking system was inconsistent and ineffective, as evidenced by the lack of documentation for behaviors such as wandering, fatigue, and trouble sleeping, despite these being noted in progress notes and the MAR. The Social Services Director (SSD) acknowledged the absence of a comprehensive tracking system and indicated that behaviors were not consistently documented across different records, leading to a failure to complete a Behavior Risk Assessment after Resident B's elopement. Resident B had a history of elopement and wore a WanderGuard, yet the facility did not track his wandering behaviors, considering them normal activity. The SSD, who started in March 2024, was in the process of implementing a tracking system but had not yet established one. The inconsistency in behavior documentation was evident as the SSD maintained a Behavior Tracking Binder, which lacked comprehensive entries for Resident B's behaviors. Additionally, the RN was unaware of Resident B's insomnia, highlighting a communication gap during shift changes. For Resident 4, the facility also failed to maintain consistent behavior tracking. The MAR, progress notes, and task portions of the clinical record showed discrepancies in documented behaviors. The SSD had not started tracking behaviors for Resident 4, and the Director of Nursing (DON) indicated that behavior reviews were based on 24-hour reports, which did not pull information from all relevant sections of the clinical record. The facility's Behavior Management policy required behavior monitoring every shift, but the documentation did not align with this policy, leading to incomplete tracking and assessment of Resident 4's behaviors.
Inaccurate Documentation for Residents' Status and Fall Risk
Penalty
Summary
The facility failed to ensure accurate documentation for two residents reviewed for accidents. Resident 4's clinical record inaccurately reflected their presence in the facility while they were hospitalized. Despite being hospitalized from July 2 to July 19, 2024, the resident's progress notes and Medication Administration Record (MAR) indicated activities and medication monitoring as if the resident were present in the facility. The Activities Director acknowledged an oversight in marking the wrong person on the log, and the Director of Nursing (DON) noted that the resident should have been marked as out of the facility, which would have prevented the incorrect documentation. For Resident 5, the facility failed to accurately document fall risk assessments. The resident, diagnosed with dementia, aphasia, depression, and a psychotic disorder, had experienced a fall on April 6, 2024. However, the fall risk assessments were inconsistent, with some indicating no falls or predisposing diseases, despite the resident's history of stroke and occasional falls due to weakness. The DON admitted that the fall risk assessments were not filled out correctly and emphasized the need for consistent protocol adherence. The facility's policy on documentation required it to be factual, objective, and accurate, which was not adhered to in these cases.
Failure to Provide Necessary Treatment and Services for Residents with Dementia
Penalty
Summary
The facility failed to provide necessary treatment and services for residents diagnosed with dementia with behavioral disturbances. Specifically, the care plans for residents were not updated following persistent behaviors, recommended treatments and orders were not followed, outside services were not updated on continuing behaviors, and residents were left unsupervised. This resulted in multiple incidents of aggressive and inappropriate behavior among residents, including physical altercations and sexually inappropriate conduct. Resident B, diagnosed with dementia with psychotic disturbance, anxiety, major depressive disorder, bipolar disorder, and conduct disorder, exhibited aggressive behaviors towards other residents. Despite being placed on 15-minute checks, documentation of these checks was inconsistent, and no new behavioral interventions were implemented since 11/17/23. Incidents included Resident B choking Resident D and engaging in a physical altercation with Resident F. Additionally, Resident B was not seen by a psychotherapist as recommended by the Psychiatric Nurse Practitioner (NP). Resident D, diagnosed with dementia with other behavioral disturbance, anxiety, paraphilia, mood disorder, psychosis, major depressive disorder, and insomnia, exhibited behaviors that distressed other residents, such as invading personal space and taunting. Despite these behaviors being documented, no new interventions were added to his care plan. Resident C, diagnosed with dementia with other behavioral disturbance, impulsiveness, and anxiety, exhibited sexually inappropriate behaviors, including exposing himself and asking another resident to perform oral sex. Despite these behaviors, no new interventions were added to his care plan since 11/30/23, and communication with psychiatric services was inadequate.
Incomplete Investigation of Verbal Abuse Allegation
Penalty
Summary
The facility failed to complete a thorough investigation for an allegation of verbal abuse involving Resident B. A nurse overheard a CNA yelling and cursing at Resident B, and the incident was reported. The facility's investigation included a statement from the accused CNA and an interview with Resident B's roommate. However, the investigation did not include an interview with another CNA who allegedly witnessed the incident, nor did it include interviews with other residents who received care from the accused CNA on the day of the incident. During interviews, the facility administrator and the DON acknowledged that the investigation was incomplete, as it did not include all potential witnesses and other residents on the unit where the alleged abuse occurred. The facility's policy on abuse prohibition and investigation requires a thorough investigation to gather pertinent information and verify the occurrence, which was not fully adhered to in this case.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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