Cumberland Pointe Health Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in West Lafayette, Indiana.
- Location
- 1051 Cumberland Ave, West Lafayette, Indiana 47906
- CMS Provider Number
- 155775
- Inspections on file
- 26
- Latest survey
- July 30, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Cumberland Pointe Health Campus during CMS and state inspections, most recent first.
A resident with significant mobility limitations and a history of falls was not assessed for or provided with bed rails despite multiple requests from the resident and his POA. During incontinence care, the resident was rolled to the edge of an elevated bed and fell, resulting in a right femoral neck fracture, scalp laceration, and multiple bruises. Facility staff did not follow policies for bed rail assessment or fall prevention, and the resident's representative was not promptly notified of the incident.
Two residents with complex medical histories had deficiencies in the documentation and updating of their advanced directives and code status. In one case, a POST form indicating DNR was not signed by a physician, and the code status was not updated to reflect the resident's wishes. In another case, conflicting code status orders were present in the EHR without a POST form, leading to confusion among staff about which order to follow. These failures resulted in the facility not ensuring residents' end-of-life care preferences were properly documented and honored.
Two residents with complex medical conditions did not have required quarterly care plan meetings documented following their MDS assessments. The DON confirmed that these meetings, mandated by facility policy, were not completed as required.
A resident with multiple chronic conditions received furosemide for blood pressure management outside of physician-ordered parameters, as the medication was administered on several occasions when the resident's systolic blood pressure was below the threshold specified in the order. Nursing staff and the DON confirmed that the medication should have been held in these instances, but it was not.
A resident admitted with an indwelling urinary catheter did not have physician's orders for catheter care and monitoring entered until five days after admission, despite facility policy requiring immediate review and implementation of standing orders. This resulted in a lack of documented catheter care and assessments in the MAR.
A resident with a g-tube received nutrition and hydration through the tube without clear physician orders specifying the route or authorization for these interventions. Staff interviews and documentation revealed that only water flushes were ordered for the g-tube, but additional fluids and supplements were administered via the tube, contrary to facility policy and physician instructions.
A resident receiving IV antibiotic therapy did not have appropriate physician orders or documentation for IV site assessments, flushes, or infection prevention measures. Staff interviews confirmed that standard IV care orders were not initiated or obtained, and required documentation was missing until several days after therapy began.
A resident with acute and chronic respiratory conditions was observed using oxygen equipment without a current physician's order, and the nasal cannula was repeatedly found on the floor rather than stored properly. The clinical record lacked an active order for oxygen therapy during the period of use, and staff confirmed the oversight, contrary to facility policy requiring documented orders and proper equipment handling.
A resident with multiple chronic conditions did not receive several prescribed medications on multiple occasions because the medications were not available from the pharmacy. The resident reported missed and delayed doses, and the DON confirmed that the medications were not administered due to unavailability, contrary to facility policy requiring timely medication administration.
The facility failed to follow physician orders and care protocols for several residents. A resident with constipation did not receive bowel protocol interventions, and another resident was not wearing prescribed compression hose. A third resident received metoprolol despite orders to hold it under certain conditions, and a fourth resident was without a required pressure-reducing cushion. Staff were unaware of reasons for non-compliance, and the facility lacked policies to ensure adherence to physician orders.
A facility failed to document a PASARR level 2 on the MDS assessment for a resident with multiple diagnoses, including cerebral palsy and major depressive disorder. Although a PASARR level 2 was completed, the annual MDS assessment did not reflect this. The MDS Clinical Support nurse confirmed the oversight and stated that the facility followed the RAI manual as a policy.
A facility failed to conduct a PASARR for a resident after prescribing Seroquel, an antipsychotic medication. The resident, with diagnoses including bipolar disorder and depression, was initially prescribed 25 mg of Seroquel, later increased to 50 mg. Despite this change, no new PASARR assessment was completed. The facility's procedure requires a PASARR for changes in status, such as starting an antipsychotic.
A resident with chronic pain did not receive prescribed doses of hydrocodone-acetaminophen due to unavailability, despite the medication being in the Emergency Drug Kit. The facility failed to notify the physician about the missed doses, contrary to their policy on emergency medication access.
The facility failed to appoint a qualified Infection Preventionist (IP) who was professionally trained and could dedicate at least part-time to the role. The Executive Director, acting as the IP, lacked a nursing degree and could not allocate sufficient time due to other responsibilities. The Assistant Director of Nursing, also acting as the IP, was not certified, leading to a deficiency in the facility's infection prevention and control program.
A resident on a gluten-free diet did not receive a full meal as per her dietary menu slip. The meal served lacked gluten-free pasta and garlic bread, which were not prepared in advance. Staff failed to communicate with the kitchen to rectify the issue promptly, resulting in the missing items being delivered late. The facility's policy on altered diet verification was not adhered to, leading to this deficiency.
A resident with metabolic encephalopathy and constipation was not provided with a divided plate as required by their care plan and physician's order. Despite the dietary menu indicating the need for a divided plate, staff served meals on regular plates, and interviews revealed a lack of awareness about the resident's dietary needs.
The facility failed to ensure staff wore appropriate hair and facial coverings in the kitchen, as observed with three staff members. One staff member was without a hairnet, another without a facial covering over his mustache, and a third had his facial hair covering under his chin. The facility's policy requires hair restraints, but these were not adhered to during the observations.
Failure to Assess and Provide Bed Rails Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with significant mobility limitations and multiple comorbidities, including congestive heart failure, dementia, diabetes, and hypertension, was not adequately protected from accident hazards during care. The resident required substantial to maximal assistance for mobility and was identified as a fall risk upon admission. Despite repeated requests from both the resident and his daughter, who was his Power of Attorney, for bed rails to be installed, no bed rail assessment was documented, and bed rails were never provided. The facility's policies required assessment and informed consent for bed rail use, but these steps were not followed. The incident occurred when a CNA was providing incontinence care and rolled the resident onto his side on a bed that was elevated to waist level. The resident, who typically used a trapeze bar for self-adjustment but not for turning, was left at the edge of the bed and subsequently fell to the floor. The fall was unwitnessed by the resident's private aide, who was not permitted to assist with care. The resident sustained a right femoral neck fracture, a left scalp laceration, a hematoma of the frontal scalp, and multiple bruises and skin tears. The resident and his daughter both reported that requests for bed rails had been made multiple times, but these were not acted upon by facility staff. Interviews with facility staff revealed that the DON relied on nursing judgment rather than completing a documented bed rail assessment, and the care plan did not include specific interventions to address the resident's risk of falling from bed during care. The facility's fall management and bed rail policies were not followed, as risk factors were not fully evaluated, and care plan interventions were insufficient to prevent the accident. The resident's daughter was not promptly notified of the fall, learning about it from a private aide instead. The lack of appropriate assessment and implementation of assistive devices directly contributed to the resident's injuries.
Failure to Update and Document Advanced Directives and Code Status
Penalty
Summary
The facility failed to ensure that residents' code statuses were accurately updated and that required physician signatures were obtained on advanced directive forms. For one resident with multiple diagnoses including diabetes, cardiomegaly, and hypertension, the clinical record showed a full code status order, while a POST form completed by the resident's POA indicated a DNR status but lacked a physician's signature. The resident herself expressed a desire to be DNR, and facility leadership acknowledged that the form should have been completed by the physician and the code status updated accordingly. Facility policy required that advanced directives be reviewed at admission and quarterly, with nursing staff responsible for confirming code status and obtaining physician orders, but this process was not followed. For another resident with immunodeficiency and other conditions, conflicting code status orders were present in the EHR, with both full code and DNR orders documented within a short period. There was no POST form in the EHR for this resident. Staff interviews revealed confusion regarding which code status to follow when discrepancies existed, with the practice being to use the highest code status. The lack of consistent documentation and failure to obtain and maintain accurate, physician-signed advanced directive forms led to deficiencies in honoring residents' wishes regarding end-of-life care.
Failure to Complete and Document Required Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were completed quarterly for two residents, as required by both facility policy and regulatory standards. For one resident with diagnoses including diabetes type 2, cardiomegaly, hypertension, obesity, and age-related physical debility, there was no documentation of care plan meetings following quarterly and annual Minimum Data Set (MDS) assessments. The Director of Nursing (DON) confirmed that these meetings should have occurred but were not documented in the clinical record. Similarly, another resident with gastrostomy status, type 2 diabetes mellitus with diabetic chronic kidney disease, and diverticulosis of the large intestine had an admission care plan conference documented, but no subsequent quarterly care plan meetings were recorded after later MDS assessments. The DON acknowledged that required quarterly care plan meetings had not been conducted for this resident. Facility policy specifies that care plan meetings should be held at least quarterly and with significant changes, but this was not followed for the residents reviewed.
Failure to Administer Blood Pressure Medication per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with diagnoses including congestive heart failure, dementia, diabetes mellitus, and hypertension did not receive blood pressure medication according to the physician's orders. The care plan specified the need for medications as ordered and monitoring for cardiovascular distress. The physician's order required that furosemide 20 mg be administered daily but held if the resident's systolic blood pressure was less than 120. Despite this, the Medication Administration Record showed that the medication was given multiple times when the resident's systolic blood pressure was below the specified threshold. Interviews with nursing staff and the DON confirmed that the medication should have been withheld when the resident's blood pressure was outside the ordered parameters. Facility policy required that current orders, including standing orders, be maintained and followed as documented in the electronic clinical record. The failure to hold the medication as ordered resulted in the administration of furosemide outside of the physician's specified parameters.
Failure to Obtain Timely Physician Orders for Catheter Care Upon Admission
Penalty
Summary
A deficiency occurred when the facility failed to obtain physician's orders for the care and monitoring of an indwelling urinary catheter upon admission for a resident with multiple diagnoses, including chronic kidney disease, diabetes mellitus, urinary tract infection, myoglobinuria, and urogenital implants. The resident was admitted with an indwelling catheter, as documented in the admission observation and data collection form. The care plan noted the presence of the catheter and included approaches such as recording urinary output and providing care per physician's orders. However, physician's orders related to the catheter, its care, and monitoring were not entered until five days after admission. Interviews with the DON and an RN confirmed that standing orders for the catheter should have been initiated upon admission and that the lack of these orders resulted in the absence of catheter care and assessment documentation in the Medication Administration Record (MAR). Facility policies required the admitting nurse to review and implement standing orders with the physician at admission, and to assess the need for continued catheterization. These procedures were not followed, leading to the deficiency.
Failure to Follow Physician Orders for G-Tube Care and Administration
Penalty
Summary
Staff failed to follow physician's orders regarding the care and use of a gastrostomy tube (g-tube) for a resident with multiple diagnoses, including gastrostomy status, type 2 diabetes mellitus with chronic kidney disease, and diverticulosis. The physician's order specified that the g-tube should be flushed with 30 ml of water three times daily. However, documentation showed that a nurse administered 120 ml of Med Pass 2.0 nutrition and 240 ml of water through the g-tube, despite no physician's order specifying the administration of Med Pass or hydration via the g-tube. Additionally, the order for Med Pass did not indicate the route of administration, and there was no order for the 240 ml water flush through the g-tube. Interviews with staff confirmed that the only authorized use of the g-tube was for 30 ml water flushes per shift, as per the physician's order. Facility policy required that the route of administration for any medication or supplement via feeding tube be clearly specified in the physician's order and documented in the medication administration record. The lack of clear orders and documentation, as well as the administration of fluids and supplements through the g-tube without proper authorization, led to the deficiency.
Failure to Implement IV Care Orders and Documentation for Resident Receiving IV Therapy
Penalty
Summary
The facility failed to implement physician's orders and follow current professional standards of practice for the maintenance and infection prevention of an intravenous (IV) line for a resident receiving IV therapy. The resident, who had diagnoses including immunodeficiency, benign neoplasm of the meninges, and osteonecrosis, had a physician's order for IV ceftriaxone but no accompanying orders for the care and use of IV pumps, tubing, syringes, or flushes. The electronic health record lacked documentation of IV site assessments, normal saline flushes, heparin lock flushes, monitoring for side effects, or PICC dressing changes until several days after the IV therapy began. Interviews with facility staff revealed that standard orders for IV care, such as flushing and site assessment, were not initiated upon admission, and the nurse on duty did not obtain the necessary orders from the physician. The facility's policy required the admitting nurse to review and verify standing orders with the physician, but this process was not followed, resulting in the absence of essential IV care orders and documentation. This deficiency was identified for one resident reviewed for IV therapy.
Failure to Ensure Physician's Order and Proper Storage for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a physician's order for oxygen therapy was in place and that oxygen equipment was stored properly for a resident with multiple respiratory and cardiac diagnoses. Observations over several days showed that the resident's oxygen concentrator was set to deliver 3 liters per minute, but the resident was not always wearing the nasal cannula, which was found lying on the floor on multiple occasions. The clinical record review revealed that there was no active physician's order for oxygen therapy until several months after the resident returned from the hospital, despite the resident's ongoing use of oxygen equipment. Additionally, the nasal cannula was not stored in a manner that would prevent contamination when not in use. The care plan noted the resident's non-compliance with physician's orders, including refusal to wear oxygen as ordered. Interviews with facility staff confirmed the absence of a current physician's order for oxygen therapy during the period in question, and facility policies required verification and documentation of such orders, as well as proper storage and administration of oxygen equipment.
Failure to Provide Timely Pharmaceutical Services Due to Medication Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, resulting in multiple instances where prescribed medications were not administered as ordered. The resident, who was cognitively intact and had diagnoses including pneumonia, COPD, pulmonary fibrosis, congestive heart failure, and chronic atrial fibrillation, reported not receiving all her medications and noted that some were given very late. Staff informed her that the medications were not administered because they had not been received from the pharmacy. A review of the Medication Administration Record (MAR) revealed that several medications, including alprazolam, calcium citrate with vitamin D, Effexor XR, gabapentin, magnesium oxide, and venlafaxine, were documented as not available and therefore not given on multiple occasions. The DON confirmed awareness of these missed doses due to unavailability. The facility's policy required adherence to the five rights of medication administration, but these were not met in this case.
Non-Compliance with Physician Orders and Care Protocols
Penalty
Summary
The facility failed to adhere to the bowel protocol for Resident 43, who had a diagnosis of metabolic encephalopathy and constipation. The resident did not have a documented bowel movement for four days, from February 11 to February 14, 2024, and the bowel protocol was not initiated as per the physician's order. The order specified a sequence of interventions, including administering a natural laxative, Milk of Magnesia, and a Dulcolax suppository, which were not followed. Additionally, Resident 43 was observed multiple times without the prescribed compression hose, despite a physician's order to apply them daily. There was no documentation to support the facility's claim that the resident's daughter requested the hose not be used due to a wound. Resident 44, diagnosed with dementia and heart conditions, was also observed without TED hose, contrary to the physician's order and care plan. The staff was unaware of the reason for the non-compliance. Similarly, Resident 15, with heart failure and hypertension, received metoprolol despite physician orders to hold the medication if the systolic blood pressure was below 110 or the heart rate was under 65 beats per minute. The medication was administered on multiple occasions when these parameters were not met, and there was no documentation indicating the medication was held. Resident 25, who had an unstageable pressure ulcer and required a pressure-reducing cushion in her wheelchair, was observed without the cushion on several occasions. The cushion was not found in the resident's room, and staff were unsure of its whereabouts. The facility lacked a policy for ensuring compliance with physician orders, as indicated by interviews with the Clinical Support Nurse and the Administrator.
Failure to Document PASARR Level 2 on MDS Assessment
Penalty
Summary
The facility failed to ensure that a PASARR (Preadmission Screening and Resident Review) level 2 was accurately documented on the comprehensive/annual MDS (Minimum Data Set) assessment for a resident. The clinical record for the resident, who had diagnoses including cerebral palsy, major depressive disorder, bipolar disorder, anxiety disorder, and insomnia, was reviewed. A PASARR level 2 was completed for the resident on a previous date, but the annual MDS assessment did not indicate that the PASARR level 2 had been completed. During an interview, the MDS Clinical Support nurse acknowledged that the MDS assessment should have been marked to reflect the completion of the PASARR level 2 and confirmed that the facility followed the RAI manual as a policy.
Failure to Complete PASARR After Antipsychotic Prescription
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) for a resident after they were prescribed an antipsychotic medication. The resident, who had diagnoses including bipolar disorder, insomnia, and depression, was initially prescribed Seroquel 25 mg at bedtime, which was later increased to 50 mg. Despite this change in medication, no subsequent PASARR assessment was conducted. The resident's previous PASARR level 2 outcome, dated prior to the prescription of Seroquel, did not include this medication. During an interview, the Assessment Clinical Support nurse confirmed that a PASARR level 2 should have been completed following the initiation of the antipsychotic medication. The facility's standard operating procedure for PASRR, which was reviewed, indicated that a change in status, such as the introduction of an antipsychotic, necessitates a new PASARR assessment.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication as ordered by the physician for a resident with chronic pain, chronic respiratory failure, and type 2 diabetes mellitus. The resident reported experiencing pain due to not receiving her medications on time. The care plan indicated the resident was at risk for pain and required medications to be administered as ordered. However, the Medication Administration Record showed that the resident did not receive the prescribed doses of hydrocodone-acetaminophen on a specific date because the medication was not available, and staff were waiting for the pharmacy. The Clinical Support Nurse confirmed that the facility had the medication available in the Emergency Drug Kit, but staff did not utilize it. Additionally, there was no documentation in the electronic health record indicating that the physician was notified about the missed doses. The facility's policy on medication ordering and receiving from the pharmacy stated that emergency pharmacy services are available 24/7, and medications can be obtained from the emergency supply or by special order. However, the staff failed to follow this policy, resulting in the resident not receiving the necessary pain management.
Inadequate Qualification and Time Dedication of Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) was professionally trained in a relevant field such as nursing, medical technology, microbiology, or epidemiology. During an interview, the Executive Director, who was acting as the IP, indicated that she had taken continuing education unit (CEU) classes for the role. However, she did not possess a nursing degree and could not dedicate part-time to the IP role due to her responsibilities in overseeing the day-to-day operations of the facility. Additionally, the Assistant Director of Nursing (ADON), who was the acting IP, had not passed the necessary testing and was not certified. The State Operations Manual (SOM) specifies that the IP must be professionally trained and able to dedicate at least part-time to the role, based on the facility's assessment of its needs. The facility's failure to appoint a qualified IP who could fulfill these requirements led to the deficiency. The report highlights that the IP must have the necessary time to assess, develop, implement, monitor, and manage the Infection Prevention and Control Program (IPCP) effectively, which was not the case in this facility.
Failure to Provide Timely Gluten-Free Meal
Penalty
Summary
The facility failed to provide a full meal in a timely manner to a resident on a gluten-free diet. During a dining observation, Resident 43 was served a meal that did not include all the gluten-free items specified on her dietary menu slip. The resident's meal consisted of chicken, brussels sprouts, and a dessert, whereas the menu indicated she should have received caprese chicken with gluten-free pasta, roasted brussels sprouts, gluten-free garlic bread, and lemon mousse. The discrepancy was noted during an observation at 12:13 p.m., and by 12:44 p.m., the resident still had not received the gluten-free garlic bread or pasta. Interviews with staff revealed that the gluten-free items were not prepared in advance, and there was a failure to communicate with the kitchen to rectify the situation promptly. [NAME] 12 admitted to not calling the kitchen to prepare the missing items, and the Dietary Manager later confirmed that the missing items were only delivered around 1:00 p.m. The facility's policy on altered diet verification, which requires meals to be plated according to diet requirements listed on the tray card, was not followed, leading to the deficiency.
Failure to Provide Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide adaptive dining equipment for a resident who required it, as observed during multiple dining sessions. On two separate occasions, the resident was served meals on regular plates instead of the prescribed divided plate. The resident's care plan, initiated in February, and a physician's order from May both indicated the need for a divided plate at meals. Despite these directives, the staff did not adhere to the dietary requirements, as evidenced by the observations and interviews conducted. The resident in question had diagnoses including metabolic encephalopathy and constipation, which necessitated the use of a divided plate to assist with feeding. Interviews with staff revealed a lack of awareness and communication regarding the resident's dietary needs. The Dietary Manager confirmed that the resident's menu ticket specified the use of a divided plate, and the facility's policy required staff to ensure the provision of appropriate assistive devices. However, this policy was not followed, leading to the deficiency noted in the report.
Non-compliance with Hair Restraint Policy in Kitchen
Penalty
Summary
The facility failed to ensure that staff members adhered to the policy of wearing appropriate hair and facial coverings while in the kitchen. During a random observation, three staff members were found not complying with the facility's hair restraint policy. Staff Member 52 was observed in the kitchen without a hairnet, and [NAME] 6 was seen without a facial covering over his mustache. Additionally, Kitchen Employee 13 was noted to have his facial hair covering under his chin, which he admitted was due to forgetting to put it back on. The facility's policy, last approved in January 2024, mandates that employees wear hair restraints such as hats, hair coverings or nets, and beard restraints while in the kitchen.
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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