Creekside Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 3114 East 46th Street, Indianapolis, Indiana 46205
- CMS Provider Number
- 155628
- Inspections on file
- 50
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Creekside Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with delusional disorder and anxiety was prescribed and routinely received risperidone twice daily, as documented in physician orders and MARs during the seven-day look-back period for an annual MDS assessment. However, the MDS medication section was coded to show that no antipsychotic medications were received. The MDS Coordinator later acknowledged this was an error, resulting in inaccurate assessment documentation contrary to CMS RAI requirements.
Staff failed to treat a resident with dignity and respect by entering the room without knocking and speaking in a disrespectful manner regarding pain medication administration. The resident, who was moderately cognitively impaired and experiencing severe depression, expressed distress over these interactions, and staff interviews confirmed the facility's expectations for respectful communication and privacy.
A resident with dementia and rheumatoid arthritis experienced changes in muscle relaxant medications, including the restart and dosage increase of Baclofen, without timely notification to the resident's representative as required by facility policy. The lack of notification was confirmed through record review and staff interviews, and the resident was later hospitalized for acute encephalopathy and polypharmacy related to the medication changes.
A resident with multiple sclerosis and hypertension was transferred to a hospital without a physician's order or proper documentation, such as an SBAR form, to indicate the reason for transfer. Staff interviews revealed confusion about the rationale for the transfer, and the receiving hospital had to contact the facility for clarification. The facility did not issue a formal 30-day discharge notice, and there was inadequate communication and documentation as required by facility policy.
A facility failed to develop a baseline care plan within 48 hours for a resident admitted with a stage 2 pressure ulcer and severe cognitive impairment. Despite assessments and care orders being in place, no baseline care plan was created for the resident's skin concerns. Interviews revealed that the responsibility for care plans lay with the MDS staff and Wound Nurse, and the issue had been identified in the facility's QAPI process.
A resident with severe cognitive impairment and a stage 2 pressure ulcer was admitted to the facility without a comprehensive care plan addressing skin concerns. Despite assessments and care orders being in place, the facility failed to create a care plan, as revealed in interviews with the Wound Nurse and DON. This issue was previously identified and included in the facility's QAPI process, but a gap in care planning procedures remained.
A resident with hemiplegia and muscle weakness fell twice due to inadequate assistance during transfers, resulting in a head injury and a fractured arm. Another resident was transferred without a gait belt, and a third resident with cerebral palsy fell from bed during care, highlighting failures in following care plans and safety protocols.
The facility failed to maintain resident dignity and respect, as residents reported staff rudeness, lack of compassion, and inappropriate comments. Staff were loud during sleeping hours and often ignored call lights. Specific incidents included a CNA instructing a resident to have a bowel movement in bed and neglect of incontinent care. Most affected residents were cognitively intact, validating their complaints.
The facility failed to conduct quarterly care plan meetings for two residents, one with depression and hypertension, and another with multiple diagnoses including hypertension and diabetes. Both residents were cognitively intact but were not aware of or invited to regular care plan meetings. The Social Service Director cited excessive workload as a reason for the missed meetings, despite the facility's policy supporting resident participation in care planning.
A resident with hemiplegia did not receive routine oral care and timely incontinence care as per their care plan. The resident reported that staff did not assist with brushing teeth and instructed them to use their brief for bowel movements. Observations confirmed inadequate oral hygiene and delayed brief changes, with staff failing to properly cleanse and dry the resident during incontinence care. Interviews revealed inconsistencies in care provision, with staff indicating that oral care should have been done by the night shift and residents should be changed every two hours.
A facility failed to conduct required pre and post dialysis assessments for a resident with end stage renal disease. Despite a care plan outlining the need for monitoring side effects of dialysis, assessments were missing for several dates. The DON confirmed the absence of these assessments, which are mandated by the facility's policy to ensure resident safety.
Failure to Accurately Code Antipsychotic Use on MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to accurately document a resident’s antipsychotic medication use on an annual Minimum Data Set (MDS) assessment. Resident D had diagnoses including delusional disorder and anxiety. Physician orders revised in early September indicated the resident was prescribed risperidone 0.25 mg twice daily for delusional disorder. Medication Administration Records for January and February showed the resident routinely received risperidone twice daily during the seven-day look-back period for the annual MDS assessment dated early February. Despite this documented and administered antipsychotic therapy, the MDS assessment’s medication section indicated that the resident had not received any antipsychotic medications during the look-back period. During an interview, the MDS Coordinator, who had over one year of experience at the facility and over five years of MDS experience, acknowledged that the medication section of the MDS contained an error. The CMS RAI User’s Manual requires that the MDS identify, by pharmacological category, any medication received in the last seven days, but this requirement was not met for Resident D’s antipsychotic medication use.
Failure to Honor Resident Dignity and Respect
Penalty
Summary
A deficiency was identified when staff failed to treat a resident with dignity and respect. The resident, who had diagnoses including depression and right knee pain, was assessed as moderately cognitively impaired with severe depression. On multiple occasions, staff entered the resident's room without knocking, despite the resident expressing that this behavior bothered him. During one observation, a CNA entered the room without knocking to check on the resident, who later confirmed that staff frequently entered without knocking and that it was upsetting to him. Additionally, a QMA interacted with the resident in a manner that was not respectful. When the resident inquired about his pain medications, the QMA responded in a sharp tone, questioned his understanding of his medication schedule, and threatened to record a refusal and discard his medication if he did not take it immediately. The resident became tearful and reported that staff often spoke to him disrespectfully, making him feel as though there was something wrong with him. Interviews with staff and facility leadership confirmed that the expectation was for staff to knock before entering and to treat residents with dignity and respect.
Failure to Notify Resident Representative of Medication Changes
Penalty
Summary
The facility failed to timely notify a resident's representative of medication changes for a resident diagnosed with dementia and rheumatoid arthritis. The resident, who was cognitively intact according to a recent assessment, experienced increased confusion and lethargy after taking Baclofen, leading to the discontinuation of several medications, including Baclofen. Later, due to ongoing muscle spasms and pain, Baclofen was restarted and its dosage was subsequently increased. However, there was no documentation in the clinical record that the resident's representative was notified of either the restart or the dosage increase, despite special instructions in the resident's profile to notify the family of any medication changes. Nursing notes indicated that the resident became confused and semi-conscious, prompting notification of the physician, DON, and family, and a subsequent reduction in Baclofen dosage. The resident's daughter later requested transfer to the ER after observing slurred speech, and the resident was admitted to the hospital for polypharmacy, acute encephalopathy, and hypertensive urgency, with hospital records linking the altered mental status to increased Baclofen dosing. Interviews confirmed that the family had not been notified of the medication changes, and staff expressed uncertainty about who was responsible for family notification. The facility's policy required prompt notification of the resident's representative for changes in treatment, including new or discontinued medications.
Failure to Document and Communicate Resident Transfer to Hospital
Penalty
Summary
The facility failed to properly document the reason for transferring a resident to a local hospital and did not ensure appropriate communication with the receiving health facility. The clinical record for the resident, who had diagnoses including multiple sclerosis and hypertension, did not contain a physician's order for the hospital transfer, nor did it include a Situation, Background, Assessment, and Recommendation (SBAR) form to indicate the change in condition that prompted the transfer. Nursing notes indicated the resident was sent to the emergency room due to a decline in condition, but staff interviews revealed uncertainty about the specific reason for the transfer and a lack of documentation regarding what information was sent with the resident. The resident's care plan had been focused on discharge home with her spouse, and she had recently been referred to hospice services following a decline in her condition and the end of Medicare Part A coverage. Interviews with staff and the resident's family member revealed that discussions about an outstanding balance and the possibility of inpatient hospice occurred, but no formal 30-day discharge notice was issued. The family was informed that if payment was not received by midnight, the resident would be discharged to an inpatient hospice program, yet there was confusion among staff about the process and rationale for the late-night transfer to the hospital. Further, the receiving hospital contacted the facility to clarify the reason for the transfer, indicating a lack of clear communication. The facility's own policy required a physician's order for emergency transfers and documentation of assessment findings, which were not present in this case. The resident returned from the hospital without new orders, and staff interviews confirmed that standard procedures for documenting and communicating transfers were not followed.
Failure to Develop Baseline Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with a stage 2 pressure ulcer. The resident, who had severe cognitive impairment and multiple diagnoses including metabolic encephalopathy and atherosclerotic heart disease, was admitted with a pressure ulcer to the coccyx. Despite the nursing staff obtaining an assessment of the wound, notifying the doctor and family, and having care orders in place, there was no baseline care plan developed for the resident's skin concerns or pressure ulcers. Interviews with the Wound Nurse and the Director of Nursing revealed that the responsibility for developing care plans for skin-related issues lay with the MDS staff and the Wound Nurse. The Director of Nursing acknowledged an ongoing issue with baseline care plans not being routinely conducted by floor nurses, which had been identified and addressed in the facility's Quality Assurance and Performance Improvement (QAPI) process. Despite previous in-service educational offerings on admission assessment and care plans, the deficiency persisted, as evidenced by the absence of a baseline care plan for the resident in question.
Failure to Develop Comprehensive Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with a stage 2 pressure ulcer. The resident, who had severe cognitive impairment and multiple diagnoses including metabolic encephalopathy and atherosclerotic heart disease, was admitted with a pressure ulcer to the coccyx. Despite having conducted an assessment of the wound, notifying the doctor and family, and having care orders in place, the facility did not create a care plan addressing the resident's skin concerns or pressure ulcers. Interviews with the Wound Nurse and the Director of Nursing revealed that the responsibility for developing care plans for skin-related issues lay with the Wound Nurse and MDS staff. The Director of Nursing acknowledged an ongoing issue with care plans not being routinely conducted by floor nurses, which had been identified and included in the facility's Quality Assurance and Performance Improvement process. Despite previous in-service educational offerings on admission assessment and care plans, the facility did not have a baseline care plan for the resident, highlighting a gap in the implementation of care planning procedures.
Inadequate Supervision and Assistance Leads to Resident Falls and Injuries
Penalty
Summary
The facility failed to provide adequate assistance and supervision for Resident 60, who had a history of falls and required substantial assistance for transfers due to conditions such as hemiplegia and muscle weakness. On one occasion, Resident 60 fell while being transferred from the toilet to a wheelchair by a physical therapist, resulting in a head injury. Despite this incident, the resident was later transferred by a single CNA without the use of a gait belt, leading to another fall where the resident sustained a fracture of the left upper arm. Resident B, who also required assistance due to hemiplegia, was observed being transferred from a wheelchair to the toilet without the use of a gait belt, contrary to the facility's policy. This lack of adherence to safety protocols put the resident at risk, especially on days when the resident reported difficulty with transfers. Resident 1, diagnosed with cerebral palsy and requiring total assistance for bed mobility, experienced a fall when a CNA attempted to provide perineal care alone. The resident slipped from the bed, highlighting the failure to follow the care plan that required two staff members for such tasks. These incidents demonstrate a pattern of inadequate supervision and failure to adhere to established care plans, resulting in preventable accidents and injuries.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as evidenced by multiple complaints from residents during a council meeting and individual interviews. Residents reported that staff were rude, lacked compassion, and made inappropriate comments. During sleeping hours, staff were loud, laughing, and yelling in the hallways, disturbing residents. Additionally, staff were reported to turn off call lights without returning to provide the requested assistance, and residents felt they had no choice in dining arrangements. Specific incidents included a CNA telling a resident to have a bowel movement in bed to avoid assisting them to the toilet, and another resident experiencing neglect of incontinent care needs during the third shift. Residents also reported that staff had poor attitudes and were unhelpful, particularly during shift changes when the noise level was likened to a party. These issues were corroborated by the residents' clinical records, which indicated that most of the affected residents were cognitively intact, highlighting the validity of their complaints.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings quarterly for two residents, Resident 63 and Resident 95, as required. Resident 63, who has diagnoses including depression and hypertension, was found to have had his last care plan meeting on 11/19/24, with no meetings held between 2/14/24 and 11/19/24. Despite being cognitively intact, Resident 63 was unsure of when he was last invited to a care plan meeting, suggesting a lack of communication and adherence to the quarterly schedule. The Social Service Director confirmed the gap in meetings, indicating that only two meetings were held in the specified period. Similarly, Resident 95, with diagnoses including hypertension, cocaine abuse, hemiplegia, and diabetes, was not aware of what a care plan meeting was and had not been invited to one since her admission to the facility. Although a care plan meeting was documented on 04/02/2024, there was no evidence of quarterly meetings being held. The Director of Nursing provided records indicating an invitation was extended to Resident 95's daughter, but the Social Service Director admitted that meetings were not conducted timely due to an excessive workload. The facility's policy supports resident participation in care planning, but this was not effectively implemented for these residents.
Failure to Provide Adequate Oral and Incontinence Care
Penalty
Summary
The facility failed to provide routine oral care and timely incontinence care for Resident B, who was reviewed for Activities of Daily Living (ADL) care. Resident B, diagnosed with hemiplegia secondary to a cerebral vascular accident, required assistance with oral care and substantial assistance with toileting hygiene. Despite a care plan indicating the need for oral care twice daily and assistance with incontinence care, Resident B reported that staff did not help with brushing his teeth and instructed him to have a bowel movement in his brief instead of assisting him to the toilet. Observations confirmed that Resident B had visible white debris on his teeth, indicating a lack of oral care. Additionally, Resident B's incontinence care was inadequate. He reported that his brief was not changed overnight, and observations showed that his brief was heavily saturated with urine. During an observed care session, CNA 2 did not properly cleanse or dry Resident B's genitalia before applying a new brief, contrary to the facility's perineal care policy. Interviews with staff revealed inconsistencies in the provision of care, with CNA 2 indicating that night shift should have performed oral care, and CNA 3 stating that residents are changed every two hours, which was not adhered to in Resident B's case.
Failure to Conduct Pre and Post Dialysis Assessments
Penalty
Summary
The facility failed to conduct pre and post dialysis assessments for a resident with end stage renal disease, identified as Resident 43, who required dialysis services. The resident's clinical record indicated a diagnosis of end stage renal disease, necessitating dialysis treatment. A care plan dated October 25, 2024, outlined the need for monitoring for side effects of dialysis, such as changes in consciousness, cramping, fatigue, headaches, itching, and bleeding. Despite these requirements, the facility did not have documented pre and post dialysis assessments for several dates in November and December 2024, and January 2025. The Director of Nursing confirmed the absence of these assessments during an interview on January 14, 2025, acknowledging that the staff should have conducted these evaluations. The facility's dialysis policy mandates pre and post dialysis assessments to monitor the health and safety of residents receiving dialysis. These assessments include checking the level of consciousness, vital signs, and other health indicators, with any abnormalities to be communicated to the dialysis center or physician. The lack of documentation for these assessments indicates a failure to adhere to the facility's policy and ensure appropriate monitoring of the resident's condition before and after dialysis sessions.
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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