Creasy Springs Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Lafayette, Indiana.
- Location
- 1750 S Creasy Ln, Lafayette, Indiana 47905
- CMS Provider Number
- 155777
- Inspections on file
- 25
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Creasy Springs Health Campus during CMS and state inspections, most recent first.
A resident was administered multiple medications in error after admission due to a failure in the medication transcription and verification process. An LPN transcribed the wrong medication orders, and the required second nurse check was not performed, resulting in the resident receiving 23 doses of 11 different medications not prescribed for him over several days. The error was discovered only after a review of records, despite concerns raised by the resident's family.
A resident with dementia and Alzheimer's disease, who was not identified as exit-seeking, was allowed to leave a secured unit unsupervised after a CNA mistook the individual for a visitor and opened a secured door. The resident was later found walking outside by another staff member and returned to the facility. The facility was unaware of the elopement until notified by the staff member who found the resident.
A facility failed to maintain a resident's dignity during meal service when a CNA stood while assisting a resident with feeding, contrary to facility policy. The resident, with multiple diagnoses including Alzheimer's and dementia, had a care plan addressing significant weight loss. Staff interviews confirmed that standing while feeding could intimidate residents, and the facility's guidelines emphasized the importance of promoting dignity during dining.
The facility failed to promptly implement DNR orders for two residents, despite their advance directive wishes. One resident had a signed advance directive and POST form indicating DNR, but a physician's order initially indicated full code status. Similarly, another resident's DNR status was delayed in being reflected in a physician's order. The facility's policy required review of advance directives at admission, but there were delays in updating physician orders to match residents' wishes.
A facility failed to update a resident's PASARR Level I to reflect current mental health diagnoses and medications, despite physician's orders for antidepressant and anxiety medications. The Social Service Director confirmed the oversight, which was inconsistent with the facility's policy requiring updates for severe mental illness or psychiatric medication regimens.
A resident with hypertension and chronic kidney disease received lisinopril despite physician orders to hold the medication if systolic blood pressure was below 110. The MAR showed multiple instances of administration with blood pressure readings below this threshold. Facility policies require reviewing orders and vital signs before medication administration, but these were not followed.
The facility failed to obtain a physician's order for oxygen administration for two residents, leading to a deficiency in respiratory care. One resident with pulmonary fibrosis and another with multiple health issues were both placed on oxygen without timely physician orders, contrary to facility policy.
A resident with pneumonia and impaired kidney function received double doses of Augmentin due to the facility's failure to discontinue an initial order when a new one was issued. The resident, with a GFR of 24, was administered both 500 mg and 875 mg doses from 1/27/25 to 2/2/25. The facility's MAR did not automatically update with the pharmacy's system, requiring manual discontinuation of the previous order, which was not done.
The facility failed to manage medications properly, with a compromised lorazepam card found on the 200-hall cart and an unopened insulin pen improperly stored on the 300-hall cart. Additionally, drinking cups were stored under the sink in the 200-medication room, violating facility policy.
Two residents in a LTC facility received incorrect meal consistencies due to failures in implementing hospital discharge diet orders. One resident with dysphagia was served a regular meal instead of a mechanical soft diet, while another with multiple health issues received a regular diet instead of a soft and bite-sized consistency. Staff interviews revealed communication lapses and reliance on electronic systems for diet updates, leading to these deficiencies.
A facility failed to follow infection control protocols when a QMA handled a pain pill without gloves for a resident with multiple health conditions. The QMA picked the pill from a cup with bare hands and placed it in the resident's mouth after it fell on his shirt, contrary to the facility's policy requiring gloves for handling medications.
A resident with chronic kidney disease received duplicate doses of Augmentin due to a failure in the facility's antibiotic stewardship program. The resident was prescribed two different dosages without discontinuing the initial order, leading to inappropriate medication administration. The oversight was not identified by the clinical team or the pharmacy, despite daily reviews of new antibiotic orders.
A resident with multiple health conditions did not receive an influenza vaccination in a timely manner despite signing a consent form. The facility's process involved educating the resident and ordering the vaccine, but the administration was delayed, deviating from the policy that residents receive immunizations per their request.
A resident with multiple health conditions signed a consent form for a COVID-19 vaccine, but the facility failed to administer the vaccine in a timely manner, resulting in a delay of several months. The facility's policy required timely vaccination upon consent, but the process of batching vaccines led to a significant delay.
Medication Transcription Error on Admission Leads to Multiple Medication Errors
Penalty
Summary
The facility failed to ensure that medications were transcribed correctly upon admission for a resident, resulting in significant medication errors. Upon admission, a staff member transcribed medication orders for the resident, but the orders entered into the resident's record were actually those intended for another resident. This error was not identified because the required second nurse check, as outlined in facility policy, was not completed. As a result, the resident received multiple medications that were not prescribed for him over several days. The resident's family member noticed that a staff member attempted to administer unfamiliar medications and raised concerns with the staff. Despite this, the resident continued to receive incorrect medications for several days. The clinical record review confirmed that 11 medications not ordered by the transferring hospital were administered in error, with a total of 23 incorrect doses given over four days. The medications included drugs for Alzheimer's disease, overactive bladder, anxiety, high blood pressure, diarrhea, stomach acid, potassium supplementation, pain, depression, nausea, and constipation. The facility's own policies required that all new admission orders be double-checked by a second nurse and that the five rights of medication administration be followed. However, these procedures were not followed in this case, leading to the administration of multiple incorrect medications. The error was only discovered after several days when a review of the records was conducted, confirming that the resident had received medications intended for another individual.
Resident with Dementia Allowed to Exit Secured Unit Unsupervised
Penalty
Summary
A resident with dementia and Alzheimer's disease, newly admitted to the secured locked unit, was able to leave the facility unsupervised. The resident was not identified as exit-seeking and had no history of elopement according to the admission assessment. On the day of the incident, a CNA responded to a door alarm and, after interacting with the resident who requested to go outside, allowed the resident to exit through a secured door by entering the code. The CNA mistook the resident for a visitor and did not provide supervision as the resident left the building. The resident was later observed by another staff member walking on a sidewalk away from the facility and was subsequently escorted back. The facility was unaware of the resident's elopement until notified by the staff member who found the resident. Documentation confirmed that the door alarm functioned as intended, but staff failed to follow elopement prevention protocols, resulting in the resident being unsupervised outside the facility for a period of time.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity during meal service. During an observation, a Certified Nursing Assistant (CNA) was seen standing while assisting a resident with feeding in the dining room. The CNA remained standing for the entirety of the meal, which is against the facility's policy that requires staff to sit at eye level with residents while assisting them with eating. This action was observed despite the facility's guidelines emphasizing the importance of promoting resident independence and dignity during dining. The resident involved had a clinical record indicating diagnoses such as Alzheimer's, hypertensive, anxiety disorder, tachycardia, dementia, and acute kidney failure. The care plan for the resident, who had experienced significant weight loss, included interventions like offering encouragement and assistance with eating. Interviews with staff revealed that standing while feeding residents could make them feel intimidated, and it was acknowledged by the CNA involved that this practice was not appropriate. The facility's documents and policies clearly outlined the expectation for staff to treat residents with dignity and respect, including during meal times.
Failure to Implement DNR Orders Promptly
Penalty
Summary
The facility failed to promptly implement a do not resuscitate (DNR) order for two residents, despite their advance directive wishes. Resident 152 had a signed Indiana advance directive form and a Physician Orders for Scope of Treatment (POST) form indicating a DNR status, yet a physician's order dated 1/23/25 indicated full code status. It was not until 1/24/25 that a physician's order reflected the resident's DNR status. The Legacy Director confirmed that the facility's process involved meeting with residents and their representatives to discuss code status, ensuring paperwork was signed, and updating the electronic medical record. However, there was a delay in aligning the physician's order with the resident's advance directive. Similarly, Resident 160 had a signed State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order on 1/9/25, but a physician's order on 1/7/25 indicated full code status. The resident's DNR status was not reflected in a physician's order until 1/17/25. The facility's policy required that advance directives be reviewed at admission and that nursing staff obtain an order from the attending physician for the desired code status. Despite this policy, there was a delay in updating the physician's order to match the resident's advance directive, as confirmed by interviews with facility staff.
Failure to Update PASARR for Resident's Mental Health Diagnoses and Medications
Penalty
Summary
The facility failed to ensure a revised Preadmission Screen and Resident Review (PASARR) Level I was submitted to reflect a resident's current diagnoses and medications. The clinical record for a resident was reviewed, revealing diagnoses of anxiety, depression, and adjustment disorder with mixed anxiety and depressed mood. However, the PASARR Level I, dated 1/7/25, indicated no known or suspected mental health diagnoses and no mental health medications being prescribed. This was inconsistent with the physician's orders dated 1/6/25 and 1/7/25, which included prescriptions for trazodone, sertraline, and buspirone, all medications related to mental health conditions. During an interview, the Social Service Director acknowledged that a new Level I PASARR was not completed to reflect the resident's mental health diagnoses and medications. The facility's policy, as provided by the Director of Nursing, indicated that certain conditions, such as severe mental illness or a psychiatric diagnosis and medication regimen, would trigger a Level II PASARR. The failure to update the PASARR to include the resident's mental health diagnoses and medications represents a deficiency in the facility's compliance with the PASARR requirements.
Failure to Hold Medication as Ordered for Blood Pressure Parameters
Penalty
Summary
The facility failed to adhere to physician's orders regarding the administration of lisinopril for a resident with essential primary hypertension, hypertensive chronic kidney disease, and type 2 diabetes mellitus. The physician's order specified that lisinopril should be held if the resident's systolic blood pressure was less than 110. However, the Medication Administration Records (MAR) from July to October 2024 indicated that lisinopril was administered multiple times when the resident's systolic blood pressure was below the specified threshold, with readings as low as 97. An interview with a nurse confirmed that medications should be held if a resident's blood pressure is outside the hold parameters, and such instances should be documented on the MAR. The facility's policies on medication administration, which were reviewed and confirmed by the Director of Nursing and a Clinical Support nurse, emphasize the importance of reviewing and confirming medication orders and checking vital signs before administering medications. Despite these guidelines, the facility did not comply with the physician's order, leading to the administration of unnecessary medication to the resident.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen for two residents, leading to a deficiency in respiratory care. Resident 150 was observed wearing 2 liters of oxygen via nasal cannula without a prior physician's order. The resident's clinical record indicated a history of pulmonary fibrosis, chronic obstructive pulmonary disease, and other significant health issues. Despite the resident using oxygen at night in the hospital before arriving at the facility, a physician's order for oxygen was not obtained until after the resident had already been receiving oxygen at the facility. Similarly, Resident 156 was placed on oxygen due to low O2 saturations, but a physician's order was not obtained until several days later. The resident's clinical record showed a history of hemiplegia, diabetes, heart failure, and asthma. Nursing progress notes documented the resident's oxygen use, but the order for oxygen administration was delayed. The facility's policy allowed for emergency oxygen administration as a nursing intervention, but a physician's order was required thereafter, which was not promptly obtained in these cases.
Failure to Discontinue Duplicate Antibiotic Order Leads to Double Dosing
Penalty
Summary
The facility failed to ensure the discontinuation of an order for Augmentin 500 mg when a new order for Augmentin 875 mg was received, resulting in double dosing of the antibiotic for a resident with pneumonia. The resident, who had a history of hemiplegia, type 2 diabetes, chronic kidney disease, and other conditions, was administered both doses from 1/27/25 to 2/2/25. The resident's GFR was low at 24, indicating impaired kidney function, which necessitated a lower dose of Augmentin. Despite the pharmacy's usual practice of canceling duplicate orders, the facility did not send a discontinue order for the initial dose, leading to both doses being administered. Interviews with the Assistant Director of Nursing/Infection Preventionist and a pharmacist revealed that the facility's MAR did not automatically update with the pharmacy's system, requiring manual discontinuation of the previous order. The pharmacist noted that the resident should not have received the 875 mg dose due to her impaired renal function. An LPN indicated that she would verify doctor's orders and consult with a pharmacist if she encountered duplicate medications on the MAR, although she was not involved in administering the medications during the double dosing period. A Medication Error Event progress note confirmed the occurrence of the medication error due to the duplicate order.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications, leading to several deficiencies. On the 200-hall medication cart, a compromised controlled substance card of lorazepam for a resident was found with taped slots, indicating improper handling. The lorazepam tablets had expired, and there was no current order for them in the Electronic Health Record. The Licensed Practical Nurse on duty did not notice the tape during the narcotics count, and the Assistant Director of Nursing confirmed that the pills needed to be destroyed by two nurses. Additionally, on the 300-hall medication cart, an unopened Humalog insulin pen for another resident was improperly stored outside of the refrigerator, contrary to the storage instructions. The Director of Nursing confirmed that the insulin pen should have been refrigerated until needed and should be destroyed if not stored correctly. Furthermore, in the 200-medication room, drinking cups were improperly stored under the sink, which was against facility policy. The Assistant Director of Nursing acknowledged that nothing should be stored under the sink, and the cups needed to be destroyed.
Dietary Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to accurately initiate the correct diet orders upon admission for two residents, leading to inappropriate meal consistencies being served. Resident 151, who had a history of cerebrovascular accident, Alzheimer's dementia, and dysphagia, was observed receiving a regular consistency meal instead of the prescribed mechanical soft diet. The resident's hospital discharge summary recommended a Level 5 Minced and Moist diet, but due to a series of miscommunications and errors in updating the diet orders, the resident was initially served inappropriate food items. The Speech Therapist intervened, and the meal was corrected, but not before the resident had already started eating the incorrect meal. Resident 156, who had multiple health issues including hemiplegia, diabetes, and heart failure, was also affected by incorrect diet orders. The hospital discharge summary indicated a Level 6 Soft and Bite-Sized diet, but the facility ordered a regular consistency diet instead. This oversight was compounded by the resident's ongoing health issues, including pneumonia and a productive cough, which raised concerns about potential aspiration. The facility's failure to recognize and implement the correct diet order from the hospital discharge summary contributed to the resident's risk of aspiration. Interviews with facility staff revealed systemic issues in the communication and implementation of diet orders. The Director of Dining Services noted reliance on the electronic medical record system for diet order updates, which failed to capture last-minute changes. Additionally, the Clinical Support Nurse admitted to not seeing the correct diet order on the hospital discharge summary, leading to the incorrect diet being ordered. These lapses in communication and procedure resulted in the residents receiving inappropriate meals, highlighting deficiencies in the facility's dietary management processes.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for a resident. During an observation, a Qualified Medication Aide (QMA) was seen handling a pain pill without wearing gloves. The resident, who had multiple diagnoses including end-stage renal disease and chronic heart failure, requested only the pain pill from a cup containing multiple medications. The QMA picked the pill out with bare hands and handed it to the resident, who then dropped it onto his shirt. The QMA subsequently picked the pill up from the resident's shirt and placed it in his mouth without donning gloves. The facility's policy on oral medication administration requires staff to avoid touching medications unless wearing gloves, which was not followed in this instance.
Failure in Antibiotic Stewardship Leads to Duplicate Dosing
Penalty
Summary
The facility failed to ensure proper monitoring of antibiotic use under its antibiotic stewardship program, resulting in a resident receiving duplicate doses of the same antibiotic. Resident 156, who had a history of hemiplegia, diabetes, heart failure, and chronic kidney disease, was prescribed Augmentin for pneumonia. Initially, a dose of 500-125 mg was ordered, but a subsequent order increased the dosage to 875-125 mg without discontinuing the initial order. This led to the resident receiving both dosages concurrently, which was inappropriate given her renal function. The Assistant Director of Nursing/Infection Preventionist was unaware of the duplicate dosing and did not investigate the higher dosage. The pharmacy did not receive a discontinue order for the initial dose, resulting in both dosages appearing on the facility's Medication Administration Record. Despite daily reviews of new antibiotic orders, the clinical team failed to identify and address the duplicate dosing. The facility's policy on antibiotic stewardship was not effectively implemented, as evidenced by the lack of action to prevent the medication error that occurred.
Failure to Administer Timely Influenza Vaccination
Penalty
Summary
The facility failed to provide an influenza vaccination during the current influenza season for a resident who had requested it with a signed consent form. The resident, who had multiple health conditions including type 2 diabetes mellitus, chronic obstructive pulmonary disease, and Alzheimer's disease, signed a consent form for the influenza vaccine on January 2, 2024. However, the resident's medical record did not show any influenza vaccination administered between the date of the signed consent and the administration of the vaccine on October 4, 2024. Interviews with the Clinical Support Nurse and the Assistant Director of Nursing revealed that the facility's process involved educating the resident or family after consent was signed and then ordering the vaccine. The Assistant Director of Nursing mentioned that vaccines were occasionally batched but were typically administered within a few days to a week. Despite this process, the resident did not receive the influenza vaccine in a timely manner as per their request, which was a deviation from the facility's policy that stated residents would receive immunizations per their request.
Failure to Timely Administer COVID-19 Vaccine
Penalty
Summary
The facility failed to provide a COVID-19 vaccination to a resident who had requested it and signed a consent form. Resident 13, who had multiple health conditions including type 2 diabetes, chronic kidney disease, and Alzheimer's disease, signed a consent form for the COVID-19 vaccine on January 2, 2024. However, the resident's medical record did not show any vaccination administered between the date of consent and October 4, 2024, when the vaccine was finally given. Interviews with the Clinical Support Nurse and the Assistant Director of Nursing revealed that the facility's process involved educating the resident or family and then ordering the vaccine, which could sometimes be batched and administered within a few days to a week. Despite this procedure, there was a significant delay in administering the vaccine to Resident 13, which was not in accordance with the facility's policy that required residents to receive immunizations per their request upon signing the consent form.
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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