Forest Creek Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 525 E Thompson Rd, Indianapolis, Indiana 46227
- CMS Provider Number
- 155241
- Inspections on file
- 32
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Forest Creek Village during CMS and state inspections, most recent first.
A resident with chronic pain and neuropathy, documented as cognitively intact, was found with two pill cups left on the dresser in the room, one labeled with the resident's name and one unlabeled. An LPN confirmed the cups contained the resident's prescribed medications, including melatonin 5 mg and gabapentin 300 mg and 600 mg, and acknowledged they should not have been left there. Review of the record showed active physician orders for these medications but no self-medication administration assessment or physician order authorizing the resident to self-administer, despite facility policy requiring both before allowing self-administration.
Surveyors found that three resident rooms were not maintained in a clean and sanitary condition. In one room, a full urinal with dark yellow urine was left on the floor for several days. In another, the bathroom had a strong urine and feces odor, dried feces on the toilet bowl and seat, and trash cans without liners that contained feces-soiled toilet paper and a urine-soiled brief; a CNA acknowledged the cans should have been lined and emptied and housekeeping notified. In a third room, a resident reported placing a folded hospital blanket on the bathroom floor to address a leaking toilet, resulting in a dark brown–stained blanket that staff stated was changed about weekly and should not have been left on the floor.
The facility failed to maintain an effective pest control program when roach-like insects were observed in two resident rooms. In one room, a meal tray from the prior evening with leftover food and an open pudding cup remained on a dresser, and a roach-like insect was seen crawling out of the food while the resident reported not having seen a roach for about a week. In another room, a roach-like insect was seen crawling up the bathroom wall under the sink. A prior pest control report documented cockroaches in resident rooms and hallways and noted that clutter and stored items in most rooms limited access for service, despite a facility policy stating it would maintain an effective pest control program so the facility is free of pests.
An Activity Assistant took a photo of a cognitively impaired resident and posted it on social media with an inappropriate caption, without authorization from the family or facility, violating policies on mental abuse and confidentiality.
Surveyors observed a buildup of dark substance, dust, debris, a screwdriver, and plastic lids under a kitchen freezer, as well as dust and debris under dry storage shelves. The dietary supervisor confirmed these areas should have been cleaned, and facility policy requires kitchen floors to be kept clean and sanitary.
A resident with multiple comorbidities and a history of falls was found with their bed not in the lowest position, despite care plan interventions and a physician's order requiring it. A QMA confirmed the bed should not have been left elevated, and facility policy mandates implementation of person-centered care plans.
Two residents received meals that were not at a palatable or proper temperature, with one resident unable to cut her sausage and reporting cold food, and another resident leaving half her meal uneaten due to it not being hot. Both residents indicated this was a recurring issue, and food was observed sitting in the hallway before delivery, contrary to facility policy.
Staff failed to follow enhanced barrier precautions for a resident with an indwelling urinary catheter during a transfer. An LPN wore gloves but not a gown, and a CNA wore neither gloves nor a gown, despite facility policy and the resident's care plan requiring both gown and gloves for such high-contact care activities.
A buildup of a thick, black, tar-like substance mixed with hair and debris was observed along the floorboards and trim in a hallway. The DON confirmed this should have been removed during regular cleaning, and the Housekeeping Supervisor stated that staff are expected to scrape such buildup daily. The facility could not provide a related policy during the survey.
A resident with minimal cognitive impairment and multiple diagnoses was found with a senna tablet at their bedside without a completed self-medication administration assessment, as required by facility policy. Staff confirmed that the necessary assessment to determine the resident's competence for self-administration had not been performed.
A resident with neurogenic bladder, severe morbid obesity, and diabetes was admitted with an indwelling urinary catheter, as documented in clinical records and physician orders. However, the admission MDS assessment failed to indicate the presence of the catheter, contrary to RAI Manual requirements. This inaccuracy was confirmed through record review and staff interview.
Three residents with respiratory conditions did not have their oxygen tubing, nebulizer machines, or nebulizer tubing changed or cleaned as required, with equipment found stained, dusty, or not changed for extended periods. Staff confirmed the equipment should be changed weekly, but no policy was available, and physician orders for weekly changes were not followed.
Prescription medications were found unsecured on top of an unlocked medication cart in a high-traffic area without staff supervision, and two vials of prescription aerosol medication were left in a resident's room who did not have a physician's order for them. An LPN confirmed these medications should have been secured, and facility policy required all medications to be stored in locked areas inaccessible to residents and visitors.
Two residents experienced incomplete and inaccurate medical record documentation, including missing entries for nebulizer treatment administration and urinary catheter output. Observations included a dirty nebulizer machine not properly stored and multiple omissions in required documentation, with the DON confirming that all documentation should have been completed.
Surveyors found that infection control practices were not followed for three residents: a nebulizer machine and mask were left dirty and improperly stored, a urinary catheter bag was placed on the floor, and soiled linens and a brief were left on the floor. Staff interviews confirmed these actions were not in line with facility policy.
A cockroach was observed outside a resident's room, and the resident confirmed seeing the pest near his door. Review of the facility's pest control policy showed a requirement to keep the environment free from pests, but the presence of the cockroach indicated a failure to meet this standard.
Surveyors found that the facility exceeded the acceptable medication error rate, with errors including a nurse failing to instruct a resident to rinse and spit after inhaler use and not priming insulin pens before administration to another resident, contrary to medication instructions and facility protocols.
A resident with diabetes and thyroid disorder was found with multiple pills left at the bedside without staff present, and there was no completed self-administration medication assessment in the clinical record. Facility policy requires medications to be securely stored, and staff confirmed the medications should not have been left in the room.
Surveyors found that a resident's Wixela inhaler and a Lantus Solostar insulin pen on a medication cart were not dated when opened, despite facility policy requiring opened dates for medications with shortened expiration periods. An RN confirmed these items should have been dated, and the DON provided the current policy supporting this requirement.
An LPN did not perform hand hygiene before putting on gloves or after removing them while administering insulin to a resident, and exited the room wearing used gloves. The facility's policies and competencies require hand hygiene at these steps and removal of gloves before leaving the room.
The facility failed to secure hazardous materials in the Soiled Utility Room, as observed on two occasions. The room's door was found unlocked with no staff present, and sharps containers were improperly stored, exposing used needles. Both the Maintenance Director and DON confirmed the door should have been locked, as per the facility's Bloodborne Pathogens Exposure Control Plan.
The facility failed to document drug dispositions for two residents, leading to a deficiency in pharmaceutical services. One resident with Alzheimer's and another with schizophrenia were transferred or discharged without proper documentation of medications sent with them. The facility's policy requires a Product Destruction form to be completed, which was not done.
A resident with respiratory failure, COPD, opioid dependence, and hepatitis C received a Fentanyl patch on the wrong day due to a QMA's error. The patch was administered a day early without notifying the nursing staff or physician, contrary to the physician's order and facility policy. The error was discovered when the resident reported it, highlighting a failure to follow medication administration protocols.
Unassessed Self-Administration and Unsupervised Medications Left in Resident Room
Penalty
Summary
The facility failed to ensure a resident was properly assessed and authorized to self-administer medications before leaving medications unsupervised in the resident's room. During observation, two pill cups were found on the resident's dresser. One cup, labeled with the resident's name, contained an unmarked small white pill. The second, unlabeled cup contained a large piece of candy, an unmarked small white pill, a yellow capsule, and a large white tablet. An LPN compared the pills in the cups to the resident's medications and identified them as melatonin 5 mg, gabapentin 300 mg, and gabapentin 600 mg, and stated the medications should not have been left in the room. Record review showed the resident had diagnoses including chronic pain and neuropathy and was cognitively intact per an annual MDS assessment. Physician orders included gabapentin 300 mg twice daily, gabapentin 600 mg at bedtime, and melatonin 5 mg at bedtime. However, the clinical record did not contain a self-medication administration assessment or a physician's order authorizing the resident to self-administer medications. The facility's policy on self-administration of medications required completion of a self-administration assessment and a physician's order specifying the resident's ability to self-administer, but these were absent in this case.
Failure to Maintain Clean and Sanitary Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, sanitary, and safe environment in three randomly observed resident rooms. In one room, a full, closed urinal containing dark yellow urine was observed sitting on the floor near a cluttered window area with personal belongings along the wall. The resident in that room reported the urinal had been on the floor for a couple of days. When interviewed, an LPN acknowledged that the urinal should have been emptied and not left on the floor. In a second room, the bathroom had a strong odor of urine and feces, with dried feces visible on the rim of the toilet bowl and on the toilet seat. A trash can without a bag was almost full of toilet paper with dried feces on it, and another trash can without a bag contained a urine-soiled brief. A CNA stated the trash cans should have had bags and been emptied, and that staff should have notified housekeeping to clean the toilet. In a third room, a white hospital blanket folded on the bathroom floor in front of the toilet was stained dark brown. The resident reported placing a folded blanket on the floor because the toilet leaked, and that the blanket was changed every week or two. A CNA confirmed the blanket had been changed about weekly and stated it should not have been left on the floor.
Failure to Maintain Effective Pest Control in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program when roach-like insects were observed in two resident rooms during surveyor observations. In one room, a dresser held a meal tray from the previous night’s dinner with dried peas, potatoes, and an open chocolate pudding cup, and a small roach-like insect was seen crawling out of the peas; the resident in that room stated he had not seen a roach in his room for about a week and confirmed the tray was from the prior evening. In another room, a roach-like insect was observed crawling up the bathroom wall underneath the sink. A pest control report dated several months earlier documented that cockroaches had been noted in resident rooms and hallways, and that access for pest control service was limited due to clutter and stored items, with most resident rooms having too much clutter to be properly serviced. The facility’s pest control policy stated that the facility would maintain an effective pest control program so that the facility is free of pests. These observations and records show that despite an existing pest control policy and prior pest control service noting cockroach activity and access limitations, pests continued to be present in resident rooms, and environmental conditions such as clutter and leftover food impeded effective pest management.
Staff Member Posted Unauthorized Photo of Cognitively Impaired Resident Online
Penalty
Summary
A staff member, specifically an Activity Assistant, took a photograph of a resident who was severely cognitively impaired and resided on the secured memory care unit. The resident had diagnoses including Alzheimer's disease, delusional disorder, and cognitive communication deficit. The photograph depicted the resident sitting in a wheelchair holding a baby doll, staring at the camera without a smile. The image was posted online by the Activity Assistant, accompanied by a caption containing inappropriate language and referencing the resident and the baby doll. The staff member posted the photograph on a social media website without obtaining authorization from the resident's family or the facility. This action was in direct violation of the facility's policy, which prohibits mental abuse and the unauthorized sharing of confidential information. The incident was discovered and reported by the facility, and documentation confirmed that the staff member had violated both HIPAA and the facility's confidentiality policies.
Unsanitary Kitchen Floors and Storage Areas
Penalty
Summary
During a kitchen inspection, surveyors observed a buildup of an unknown dark substance, dust, debris, a screwdriver, and several plastic lids under a freezer in the main kitchen area. Additionally, there was a buildup of dust and debris under the shelves in the dry storage room. The dietary supervisor acknowledged that these areas should have been cleaned. Review of the facility's policy on cleaning floors, tables, and chairs confirmed that kitchen floors are required to be kept clean and sanitary. These findings indicate that the facility failed to maintain a sanitary environment for food service as required by professional standards.
Failure to Implement Fall Prevention Care Plan Intervention
Penalty
Summary
The facility failed to implement person-centered care plan interventions for a resident identified as high risk for falls. Observation revealed that the resident's bed was not in the lowest position, contrary to the care plan intervention and a current physician's order, both of which specified that the bed should be kept in the lowest position. The resident, who had diagnoses including congestive heart failure, diabetes, and respiratory failure, was moderately cognitively impaired and had a documented history of two or more falls with injury. During the observation, a QMA confirmed that the bed should not have been left elevated. Review of facility policy indicated that a person-centered care plan should be developed and implemented for every resident.
Failure to Serve Palatable and Properly Heated Meals
Penalty
Summary
The facility failed to ensure that meals were served to residents at a palatable and proper temperature, as required by policy. Observations showed that a meal tray for one resident was left on a metal cart in the hallway for approximately 20 minutes before being delivered to the resident's room. When the resident attempted to eat, she was unable to cut the sausage, describing it as rubbery, and indicated that her food was cold. She also stated that she rarely received hot food because it often sat in the hallway before being served. Another resident was observed eating only about half of her meal and leaving the rest uneaten, with a balled-up napkin on the plate. She reported that her food was not hot and that she did not request reheating because it took too long. The facility's current policy requires that all hot and cold food be served at a palatable temperature at the time it is received by the resident. These findings were based on direct observation, resident interviews, and a review of facility policy.
Failure to Implement Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident with an indwelling urinary catheter, as required by both the resident's care plan and facility policy. During a transfer of the resident to bed using a mechanical lift, an LPN wore gloves but did not wear a gown, and a CNA wore neither gloves nor a gown. Personal protective equipment, including gowns and gloves, was available in the resident's room, but was not utilized as required during the high-contact care activity. The CNA later confirmed in an interview that staff should have been wearing a gown and gloves during the transfer. The resident involved had a diagnosis of obstructive uropathy and a documented indwelling urinary catheter, placing them at increased risk for colonization or infection with multi-drug resistant organisms. The care plan specifically identified the need for enhanced barrier precautions, including the use of gown and gloves during transfers. The facility's current policy, provided by the Director of Nursing, also required staff to wear gown and gloves for residents with indwelling urinary catheters during transfers, but this protocol was not followed during the observed event.
Failure to Maintain Sanitary Environment Due to Floor Buildup
Penalty
Summary
During an initial tour of the 100 Hall, surveyors observed a buildup of an unknown black substance along the floorboards and floorboard trim throughout the hallway. The substance was described as thick, black, tar-like, and mixed with hair and other debris. Further observation showed approximately six inches of this substance being scraped up, confirming its unsanitary nature. The DON acknowledged that the buildup should have been removed during routine housekeeping. The Housekeeping Supervisor stated that floors are cleaned daily and staff are expected to scrape off such buildup during cleaning. The facility was unable to provide a relevant policy regarding this issue by the time of survey exit.
Failure to Complete Self-Medication Assessment for Resident
Penalty
Summary
A deficiency occurred when a resident was observed with a pill cup containing a round brown tablet, identified as senna 8.6 mg, left on their bedside table. The resident, who had diagnoses including diabetes and metabolic encephalopathy and was assessed as having minimal cognitive impairment, did not have a completed self-medication administration assessment in their clinical record. Facility staff, including an LPN and the DON, confirmed that no such assessment had been performed. The facility's policy requires an interdisciplinary team assessment of a resident's competence before allowing self-administration of medications, but this process was not followed in this instance.
Inaccurate MDS Assessment for Resident with Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident admitted with an indwelling urinary catheter. The resident, who had diagnoses including neurogenic bladder, severe morbid obesity, and diabetes, was admitted with an indwelling urinary catheter as documented in the clinical record and physician's orders. However, the admission MDS assessment did not indicate the presence of the catheter, despite the Resident Assessment Instrument (RAI) Manual requiring documentation of an indwelling urinary catheter if used at any time in the seven days prior to the assessment date. This discrepancy was confirmed through record review and staff interview.
Failure to Maintain and Change Respiratory Equipment as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not ensuring that oxygen tubing, nebulizer machines, and nebulizer tubing were properly maintained and changed as required. Observations revealed that one resident's nebulizer machine was stained, dusty, and placed on the floor, with the face mask left uncovered on a heating unit and not changed since the date marked over a month prior. Another resident's oxygen concentrator was found with humidity water and nasal cannula tubing that had not been changed for nearly two months. A third resident was observed using a nebulizer mask with mist spraying into the air, with the oxygen concentrator on the floor and humidity water not changed for almost a month. In all cases, the equipment was not maintained according to the facility's expected weekly change schedule. Interviews with staff, including an LPN and the DON, confirmed that the respiratory equipment should have been changed weekly, but there was no policy available to support this practice. The clinical records for the residents indicated diagnoses such as chronic obstructive pulmonary disease, dementia, morbid obesity, encephalopathy, and neurogenic bladder, with physician orders specifying the frequency for changing respiratory equipment. Despite these orders, the facility did not ensure compliance, resulting in the cited deficiency.
Failure to Secure Prescription Medications and Improper Medication Storage
Penalty
Summary
Surveyors observed that prescription medications were not properly secured on two separate occasions. On one occasion, two prescription medications, H-Chlor12 wound cleanser and lactulose solution, were found sitting on top of an unlocked medication cart in a high-traffic resident area without staff supervision. An LPN confirmed that these medications should have been secured and the cart locked or supervised. On another occasion, two unopened vials of albuterol inhalation solution were found in a resident's room, next to a nebulizer mask, rather than being secured in the medication cart as required. The LPN acknowledged that these medications should have been secured. A review of the resident's clinical record revealed that the resident had diagnoses including chronic obstructive pulmonary disorder, dementia, and morbid obesity. The resident had a physician's order for ipratropium-albuterol inhalation solution, but not for the albuterol inhalation solution that was found in the room. Facility policy required all medications and treatment items to be stored in a locked cabinet, cart, or medication room inaccessible to residents and visitors. These observations and record reviews demonstrated a failure to follow the facility's medication storage policy.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate documentation for two residents. For one resident with chronic obstructive pulmonary disorder, dementia, and morbid obesity, a dirty nebulizer machine was observed on the floor, with the face mask not stored in a bag and dated over a month prior. Review of the Medication Administration Record (MAR) revealed multiple instances where required documentation for administration of ipratropium-albuterol nebulizer solution was incomplete or missing, including omissions of pulse, respirations, breath sounds, and minutes of therapy before and after administration across several dates. For another resident with neurogenic bladder, severe morbid obesity, and diabetes, the physician's order required recording urine output from a urinary catheter every shift. The Treatment Administration Record (TAR) showed missing documentation of urinary output for several shifts during the period the order was active. During an interview, the Director of Nursing confirmed that all documentation should have been completed, and there was no facility policy on documentation.
Infection Control Lapses in Equipment and Linen Handling
Penalty
Summary
Surveyors observed multiple failures in infection control practices involving three residents. For one resident with chronic obstructive pulmonary disorder, dementia, and morbid obesity, a dirty nebulizer machine was found on the floor next to a heat unit, with the face mask not stored in a bag but left exposed on the heat unit. The nebulizer mask was dated over a month prior to the observation. An LPN confirmed that the nebulizer should not have been on the floor and the mask should have been bagged. The resident's clinical record indicated a physician's order for frequent nebulizer treatments. Another resident with encephalopathy and neurogenic bladder was found to have a urinary catheter bag sitting directly on the floor, containing approximately 400 ml of urine. Both a QMA and an RN acknowledged that catheter bags should not be left on the floor. In a separate incident, a soiled brief, gown, and linen were observed lying on the floor in a room of a resident with lung cancer, dementia, and dysphagia, who was always incontinent of bladder. A CNA confirmed that these soiled items should not have been left on the floor. Facility policy reviewed by the DON specified that urinary drainage bags should not touch the floor, contaminated linen should be bagged, and equipment should be stored to prevent contamination.
Failure to Maintain Pest-Free Environment
Penalty
Summary
A brown cockroach was observed crawling on the floor outside a resident's room during a random observation. At that time, the resident reported having seen a roach near his door. The facility's current pest control policy, dated September 2023, was reviewed and indicated that the facility is required to maintain an effective pest control program to ensure the environment is free from pests. Despite this policy, the presence of a cockroach was confirmed through direct observation and resident interview.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, with surveyors identifying a 16 percent error rate during their review. In one instance, a registered nurse administered Wixela and Incruse Ellipta inhalers to a resident but did not instruct the resident to rinse and spit out water after administration, as required by both the medication instructions and the facility's competency guidelines. The nurse indicated that rinsing was not necessary, despite clear instructions to the contrary. In another instance, the same nurse administered Lantus Solostar and Humalog KwikPen insulin to a different resident without priming either insulin pen prior to injection. The nurse stated that priming was not needed, although both the manufacturers' instructions and the facility's competency guidelines specify that priming is required to ensure accurate dosing. These actions were observed and confirmed through interviews and record reviews, leading to the cited deficiency.
Failure to Complete Self-Administration Medication Assessment and Improper Medication Storage
Penalty
Summary
A resident with diagnoses including diabetes and thyroid disorder was observed with three pills—a small purple pill, a small white pill, and a yellow capsule—left in a plastic medication cup on the bedside table without staff present. Staff confirmed that these medications should not have been left in the resident's room. Review of the resident's clinical record revealed there was no completed self-administration medication assessment. Facility policy requires medications to be stored in a locked cabinet, cart, or medication room inaccessible to residents and visitors. The Director of Nursing confirmed that the required assessment was not present and that medications should not have been left at the bedside.
Failure to Date Opened Medications on Medication Cart
Penalty
Summary
Surveyors observed that medications on the 200 Hall medication cart were not dated when opened, as required by facility policy and professional standards. Specifically, a Wixela inhaler prescribed for a resident with chronic obstructive pulmonary disease was found in a clear bag in the medication cart with no opened date indicated on the package or inhaler, despite the label showing it was filled with 60 doses and 47 doses remained. Additionally, a Lantus Solostar insulin pen with a broken seal was present in the same cart drawer without an opened date on the label or pen. During interviews, a registered nurse confirmed that both the inhaler and insulin pen should have been dated upon opening. The facility's current policy, provided by the Director of Nursing, requires that the date opened be documented on medication containers when the expiration date is shortened after opening.
Failure to Follow Infection Control Protocol During Insulin Administration
Penalty
Summary
A deficiency was identified when an LPN failed to follow proper infection control practices during the administration of insulin to a resident. The LPN entered the resident's room with insulin pens, donned clean gloves, and administered the insulin without performing hand hygiene beforehand. After the procedure, the LPN exited the resident's room while still wearing the used gloves and only removed them after leaving the room, again without performing hand hygiene. The LPN acknowledged the lapse in hand hygiene and glove removal protocol. Review of the facility's current skills competency and infection prevention policy confirmed that hand hygiene should be performed before donning gloves and after removing them, and gloves should be removed prior to exiting the resident's room.
Failure to Secure Hazardous Materials in Soiled Utility Room
Penalty
Summary
The facility failed to ensure that potentially hazardous materials were kept secure, as observed during two separate instances. On January 27, 2025, at 9:05 a.m., the door to the Soiled Utility Room on the west hall across from the laundry room was found unlocked with no staff present. Inside the room, four full sharps containers were observed, with one container unsecured and lying on its side, exposing used needles. The Maintenance Director confirmed that the door was supposed to be locked. Later, at 10:00 a.m., the door was again observed to be unlocked with no staff in the area. The Director of Nursing (DON) also confirmed that the door should have been locked. The facility's Bloodborne Pathogens Exposure Control Plan, revised in December 2023, was provided by the DON, which included procedures for properly sealing sharps containers.
Failure to Document Drug Dispositions for Residents
Penalty
Summary
The facility failed to document the drug dispositions for two residents, leading to a deficiency in pharmaceutical services. Resident 295, diagnosed with Alzheimer's disease and transient cerebral ischemic attack, was transferred to another facility with medications including Eliquis, Norvasc, and Vitamin D3. However, the clinical record lacked documentation of the name, type, or amount of medications sent with the resident. The Regional Director of Nursing confirmed the absence of this documentation during an interview. Similarly, Resident 91, who had diagnoses of schizophrenia and anxiety disorder, was discharged home with family. The resident's medications included Clozapine, Miralax, Terbinafine HCl, and Sertraline. Like Resident 295, the clinical record for Resident 91 also lacked documentation of the medications sent home. The facility's Drug Disposition Policy requires a Product Destruction form to be printed, signed, and placed in the resident's clinical record, which was not adhered to in these cases.
Improper Administration of Fentanyl Patch
Penalty
Summary
The facility failed to ensure proper administration of pain medication for Resident B, who was diagnosed with respiratory failure, COPD, opioid dependence, and hepatitis C. A Qualified Medication Aide (QMA 2) administered a Fentanyl transdermal patch on the wrong day, contrary to the physician's order. The order specified that the patch should be applied every three days, with the old patch removed and disposed of properly. However, QMA 2 replaced the patch a day early, on the evening of 9/28/24, without notifying licensed nursing staff, a supervisor, or the physician. This error was discovered when Resident B informed the staff the following day. The Director of Nursing (DON) confirmed that the error occurred and that the Fentanyl patch was not scheduled to be changed until the next day. The facility's policy on medication administration, which requires verification of the correct time for medication administration, was not followed. The incident was related to a complaint, and the facility's policy dated 12/1/07 was reviewed, indicating the need for adherence to medication administration protocols.
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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