George Ade Memorial Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brook, Indiana.
- Location
- 3623 East State Rd 16, Brook, Indiana 47922
- CMS Provider Number
- 155719
- Inspections on file
- 32
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at George Ade Memorial Health Care Center during CMS and state inspections, most recent first.
A resident with dementia and a high risk for falls, who was care planned for two-person assistance with ADLs, was assisted by a single CNA during a shower. The resident attempted to stand from the shower chair, fell, and sustained a laceration requiring sutures, an abrasion, and later was diagnosed with a right hip fracture. Documentation and interviews confirmed the CNA did not follow the care plan, leading to the resident's injuries and decline.
A resident with cognitive impairment and a history of falls experienced a shower fall resulting in pain and decreased mobility. Despite ongoing complaints of right leg pain and worsening ambulation, nursing staff did not perform or document timely assessments of the affected limb. The lack of thorough evaluation led to a delay in diagnosing a right hip fracture, which was only identified after significant physical changes were observed.
A resident with a history of cognitive impairment and other medical conditions was admitted with a deep tissue injury (DTI) on the left foot. The facility failed to provide timely treatment for the DTI, as documented treatment did not begin until several days after admission, despite a physician's order for daily skin prep. The Director of Nursing acknowledged that treatment should have been initiated immediately, highlighting a deficiency in adhering to the facility's policy on pressure ulcer care.
A resident with a history of falls and cognitive impairment was observed multiple times without anti-rollback bars on her wheelchair, despite a care plan intervention requiring them. The resident had previously fallen and sustained injuries, and the facility's policy emphasized the need for safety interventions. The DON confirmed the bars should have been in place, indicating a failure to provide a safe environment.
A facility failed to provide proper oxygen therapy for a resident with chronic respiratory failure and heart failure. The resident was observed multiple times without oxygen, despite having a physician's order for 2-4 liters per nasal cannula every shift. The MAR indicated oxygen was signed off as administered, but the rate was not documented, and there were no documented refusals. The facility's policy required documentation of liter flow and response, which was not consistently followed.
A facility failed to assess the necessity for bed rails for a resident with cognitive impairment and receiving hospice services. The resident was observed with half-length side rails without any documented evaluation or assessment, and the Physician's Order Summary lacked orders for side rails. The DON acknowledged the absence of an assessment and was unsure if other interventions were attempted. A Side Rail Assessment was later provided, indicating the use of side rails for assistance with transfers and bed mobility.
The facility failed to maintain the dignity of two residents by not covering their urinary drainage bags, as required by policy. One resident with cerebral palsy and intellectual disabilities was observed with an uncovered bag multiple times. Another resident with dementia and urinary retention had an uncovered bag until after morning care. The facility's policy mandates the use of covers to preserve dignity.
The facility failed to provide necessary assistance with ADLs for two residents, specifically in oral care and eyeglass placement. A resident with Alzheimer's did not receive oral care as required by her care plan, and another resident with dementia did not receive oral care or have his eyeglasses placed, despite facility policies mandating these actions.
A resident with a urinary catheter did not receive proper care, as observed when a CNA placed the drainage bag and tubing on the floor multiple times during morning care. The outlet tube was not disinfected after emptying, and the catheter was not washed. The resident had a history of urinary tract infections, and the care plan required the drainage system to be kept off the floor and catheter care to be completed regularly, which was not adhered to.
The facility failed to ensure staff used PPE for residents on Enhanced Barrier Precautions (EBP). Two CNAs were observed entering residents' rooms without PPE, despite signs indicating EBP. The residents had conditions requiring EBP, and care plans specified PPE use. The facility's policy required gowns and gloves to be available near the rooms.
Failure to Provide Required Two-Person Assistance Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) provided shower assistance to a resident who was care planned for two-person assistance with activities of daily living (ADLs), including bathing and transfers. The resident had a history of Alzheimer's disease, dementia, moderate intellectual disabilities, and was identified as high risk for falls. The care plan specifically required care in pairs due to the resident's cognitive impairment, fall risk, and behavioral concerns, including threatening harm to staff. Despite these documented interventions, the CNA assisted the resident alone in the shower. During the shower, the resident attempted to stand from the shower chair without adequate support, resulting in a fall. The resident sustained a laceration above the right eye requiring four sutures, an abrasion to the right knee, and was transferred to the emergency room for evaluation. Initial assessments and imaging did not reveal a hip fracture, but the resident subsequently experienced a decline in mobility, increased pain, and difficulty ambulating. Over the following days, the resident's right leg became painful, discolored, and showed signs of injury, eventually leading to the diagnosis of a right femoral neck fracture eight days after the fall. Interviews and documentation confirmed that the CNA was aware of the care plan requirement for two-person assistance but proceeded alone. The Director of Nursing and the attending physician both indicated that the hip fracture was likely caused by the fall during the unsupervised shower. The facility's failure to follow the care plan and provide adequate supervision and assistance directly resulted in the resident's injuries and subsequent decline in function.
Failure to Assess and Respond to Change in Condition After Fall
Penalty
Summary
The facility failed to ensure that a resident received care in accordance with professional standards of practice following a fall, specifically by not conducting timely and thorough assessments after changes in the resident's condition. The resident, who had diagnoses including right hip fracture, Alzheimer's disease, dementia, and moderate intellectual disabilities, experienced a fall in the shower resulting in a laceration above the right eye and an abrasion to the right knee. After returning from the emergency room, the resident began to complain of right knee and leg pain and was placed in a wheelchair for safety. Despite these complaints and a recommendation for the physician to evaluate the leg, documentation shows that nursing staff did not perform or document comprehensive assessments of the right leg on multiple occasions over several days as the resident's pain and functional status worsened. Throughout the days following the fall, the resident exhibited increasing pain, difficulty with ambulation, and changes in mobility, including refusal to walk, reliance on a wheelchair, and eventually inability to stand without assistance. Nursing notes repeatedly failed to document assessments of the right leg even when pain was reported by the resident or observed by staff. It was not until several days after the initial fall, when the resident's right leg appeared shorter, discolored, and rotated, that an x-ray was ordered, revealing a right femoral neck fracture. Prior to this, only a right knee x-ray had been obtained, which was negative for injury, and the resident continued to experience significant pain and decreased mobility. Interviews with facility staff, including the PT and DON, confirmed that the resident's pain and functional decline were not adequately assessed or addressed in a timely manner. The DON acknowledged that no further assessments were completed by nurses when the resident's right leg pain increased and his functional status changed, until the significant physical changes were observed. This lack of timely and thorough assessment delayed the diagnosis and treatment of the resident's fractured right hip.
Failure to Provide Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide timely treatment for a resident with a pressure ulcer, leading to a deficiency in care. The resident, who was cognitively impaired and had a history of hypertension, cerebral infarction, and Alzheimer's disease, was admitted to the facility with a deep tissue injury (DTI) on the left foot. Upon admission, the DTI was noted to be a dark brownish purple area measuring 0.8 cm x 3 cm. Despite the presence of the DTI, the Treatment Administration Record (TAR) showed no documented treatment for the left lateral foot from the time of admission on November 22, 2024, until November 26, 2024, when a physician's order for daily skin prep was received. The deficiency was further highlighted during an interview with the Director of Nursing (DON), who acknowledged that a treatment plan should have been implemented immediately upon identifying the DTI. The facility's policy on Skin Condition and Pressure Ulcer Assessment mandates that at the earliest sign of a pressure ulcer, the resident, legal representative, and attending physician should be notified, and the condition should be documented in the nursing notes. However, the lack of timely treatment and documentation for the resident's DTI indicates a failure to adhere to this policy, resulting in inadequate care for the resident.
Failure to Implement Fall Precautions for Resident
Penalty
Summary
The facility failed to ensure fall precautions were in place for a resident with a history of falls. Resident 52, who was cognitively impaired and had a history of falls, was observed multiple times without anti-rollback bars on her wheelchair, despite a care plan intervention indicating their necessity. The resident's diagnoses included dementia with behavioral disturbance, anxiety disorder, and hypertension, and she required partial to moderate staff assistance with bed mobility. The resident had previously fallen and sustained injuries, prompting the interdisciplinary team to decide on the application of anti-rollback bars for her wheelchair. Observations on three separate occasions revealed that the anti-rollback bars were not present on the resident's wheelchair, contrary to the care plan's directives. The Director of Nursing confirmed that the anti-rollback bars should have been in place. The facility's Fall Prevention policy emphasized the need for safety interventions based on initial assessments, yet the required intervention for this resident was not implemented, leading to a deficiency in providing a safe environment for the resident.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure proper treatment and care related to oxygen administration for a resident with chronic respiratory conditions. Resident 4, who has diagnoses including congestive heart failure, chronic respiratory failure, and type 2 diabetes mellitus, was observed multiple times without oxygen in place, despite having a physician's order for oxygen administration of 2-4 liters per nasal cannula every shift. The resident's care plan indicated the need for oxygen therapy due to heart failure and chronic respiratory failure, with interventions to administer oxygen as ordered and as needed. The Medication Administration Record (MAR) for January 2025 showed that oxygen was signed off as administered every shift, but there was no documentation of the rate of oxygen administered or any refusals by the resident. Progress notes indicated that the resident sometimes refused oxygen during the day and was oxygen-dependent at night. However, there were no documented refusals in the MAR. The Director of Nursing later indicated that the physician had been updated, and the oxygen orders were changed to PRN. The facility's policy on oxygen therapy required documentation of the liter flow and response to treatment, which was not consistently followed.
Failure to Assess Necessity for Bed Rails
Penalty
Summary
The facility failed to attempt alternative measures and assess the necessity for bed rails for a resident reviewed for bed rails. The resident, who was cognitively impaired and receiving hospice services, was observed on two occasions with half-length side rails on both sides of the bed. The resident's record indicated diagnoses of dementia with behavioral disturbance, anxiety disorder, and hypertension. The Significant Change Minimum Data Set (MDS) assessment noted that the resident required partial to moderate staff assistance with bed mobility and that bed rails were not used as a physical restraint. However, there was no documented evaluation or assessment for the use of side rails, and the Physician's Order Summary lacked any orders for side rails. During an interview, the Director of Nursing (DON) acknowledged the absence of an assessment for the side rails and was unsure if any other interventions had been attempted prior to their use. A Side Rail Assessment was later provided, indicating the use of bilateral top half side rails for assistance with transfers and bed mobility. The facility's policy on side rails stated that an assessment should be performed to determine the need for full-length side rails to treat medical symptoms, and the use of full side rails requires a Physician's Order. The policy also mentioned that a half side rail should be used in accordance with assessed need and resident desires.
Failure to Cover Urinary Drainage Bags Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure the dignity of residents by not covering urinary drainage bags, as observed in two residents. Resident C was seen multiple times with an uncovered urinary drainage bag attached to the side of the bed, visible from the door. Resident C's medical history includes cerebral palsy and moderate intellectual disabilities, with a moderately impaired cognitive status and dependency on activities of daily living, as noted in a recent MDS assessment. Similarly, Resident D was observed with an uncovered urinary drainage bag while asleep and later when awake. Despite being assisted by a CNA, the urinary drainage bag remained uncovered until after morning care. Resident D's medical history includes dementia, a history of urinary tract infections, and urinary retention, with a moderately impaired cognitive status requiring supervision for hygiene. The facility's urinary catheter care policy mandates the use of catheter covers to preserve residents' dignity, which was not adhered to in these instances.
Failure to Provide Oral Care and Eyeglass Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, specifically in the areas of oral care and the placement of eyeglasses. Resident B, who has Alzheimer's disease and is dependent on staff for hygiene, was observed being transferred from bed to a Broda Chair without receiving oral care, despite her care plan indicating the need for assistance with oral hygiene twice daily. Similarly, Resident D, with a history of dementia and urinary issues, was observed receiving morning care without oral care being completed or eyeglasses being placed, even though his care plan required assistance with oral hygiene for his upper denture and lower natural teeth twice a day. The facility's policies, as confirmed by the Director of Nursing, require oral hygiene to be part of morning and evening care, and eyeglasses to be cleaned and placed on residents. However, these policies were not followed for Residents B and D. Interviews with staff revealed that oral care was expected to be provided daily, and while Resident D sometimes refused to wear glasses, there was no indication that this was the case during the observed deficiency. The failure to adhere to these care plans and policies resulted in the cited deficiencies.
Improper Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide proper care for a resident with a urinary catheter, leading to a deficiency in catheter management and infection prevention. During an observation, a CNA was seen placing the urinary drainage bag on the floor multiple times while assisting the resident with morning care. The catheter tubing was also on the floor, and the resident was observed rolling the tubing with his foot. After draining the urine from the bag, the CNA did not disinfect the outlet tube before clamping it and returning it to the holder. The urinary catheter was not washed during the care process, and the drainage bag was placed under the wheelchair seat with the tubing still on the floor. The resident involved had a history of urinary tract infections and urinary retention, with a care plan indicating a risk for infections due to the indwelling catheter. The care plan specified that the urinary drainage bag should be stored in a protective bag, the drainage system should not touch the floor, and catheter care should be completed every shift and as needed. The facility's urinary catheter care policy also required that the drainage bags and tubing be positioned to prevent contact with the floor and that outlet tubes be disinfected after emptying. However, these protocols were not followed, as observed during the survey.
Failure to Use PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members when providing care to residents under Enhanced Barrier Precautions (EBP). During an observation, CNA 1 entered a resident's room without wearing any PPE, despite a sign above the bed indicating the need for EBP. The resident had a history of dementia, urinary tract infections, and urinary retention, and required moderate assistance for daily activities. The care plan and physician's order specified the use of PPE, including gowns and gloves, during care. Similarly, CNA 6 was observed preparing to provide care to another resident without PPE. This resident had cerebral palsy and moderate intellectual disabilities, and was dependent on assistance for all activities of daily living. The care plan and physician's order also required EBP, with PPE to be used during care. The Director of Nursing noted that EBP signs had been moved to above the residents' beds for confidentiality, but the facility's policy required gowns and gloves to be available near or outside the resident's room.
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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