Grey Stone Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Wayne, Indiana.
- Location
- 10445 Dupont Oaks Blvd, Fort Wayne, Indiana 46845
- CMS Provider Number
- 155809
- Inspections on file
- 38
- Latest survey
- October 24, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Grey Stone Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and on anticoagulant therapy experienced a decline in condition over several weeks, but was not assessed or monitored daily as required. STAT labs were ordered after the resident showed signs of bleeding, but there was no documentation that these labs were completed or that results were communicated to the provider. Critical lab values indicating a significant drop in hemoglobin were not promptly reported, and there were gaps in assessment documentation. The lack of timely follow-up and provider notification led to the resident's hospitalization for gastrointestinal bleeding and blood transfusion.
A resident with dementia and recent hip surgery, dependent on staff for care, was left in a recliner overnight without repositioning or incontinence care, resulting in the development and worsening of a pressure ulcer on the heel. Staff failed to implement timely pressure prevention interventions, did not consistently use protective devices, and did not document care refusals, leading to the progression of the wound.
A resident with a recent hip fracture and surgery developed redness, swelling, and pain in the leg, prompting a NP to order a doppler ultrasound to rule out a blood clot. The order was not entered or completed in a timely manner, and staff failed to document ongoing assessments or communicate the lack of progress. The resident's condition worsened, leading to hospitalization for extensive blood clots and subsequent death.
A resident with a history of colostomy, recurrent small bowel obstructions, and CHF experienced several days of vomiting and no colostomy output, but staff did not promptly notify the physician or nurse practitioner of these changes. Despite multiple staff being aware of the symptoms, there was a lack of timely assessment and escalation, and the care plan did not include monitoring for small bowel obstruction. The resident was eventually sent to the hospital in critical condition and passed away from a small bowel obstruction.
A resident with a history of GERD and gout brought home medications to the facility for short-term rehab. After discharge, the resident reported that two bottles of medication were missing. The medications had been placed in blue bags on the nurse's station desk, and the LPN did not see who picked them up. The facility was unable to locate the medications, and the resident filed a police report. The Administrator acknowledged that the incident was not reported according to facility policy, which requires immediate reporting of misappropriation of resident property.
Two residents' home medications were not properly reconciled or securely stored, resulting in missing medications and the erroneous return of another resident's medications. An LPN left multiple bags of medications, including those belonging to different residents, unsecured at the nurse's station, and there was no documentation of when medications were received or returned. Facility policy requiring documentation and secure storage of home medications was not followed.
A resident with vascular dementia was allegedly hit by a visitor, resulting in a black eye, but the incident was not reported or investigated as required. The following day, the resident was found with additional injuries, yet there was no documentation or reporting of the incident. The facility's policy mandates immediate reporting and investigation of such incidents, which was not followed.
The facility failed to investigate allegations of abuse and injury for two residents. A resident with dementia was involved in an altercation with a visitor, resulting in injuries that were not immediately investigated. The facility's policy requires immediate investigation of such incidents, but this was not followed, leading to a deficiency in ensuring resident safety.
A facility failed to monitor and assess a resident for recurrent urinary retention, leading to a serious health condition. The resident, with dementia and anxiety disorder, was dependent on staff for toileting. Despite a care plan, there was no follow-up on urinary retention observed, and the resident experienced anxiety and low oxygen levels. Hospital records later showed sepsis due to E. Coli bacteremia from a urinary tract infection and urinary retention. The facility lacked a policy for monitoring urinary retention, and documentation showed no urine output for multiple shifts.
A resident admitted without skin impairment developed a stage three pressure ulcer due to the facility's failure to implement effective pressure ulcer prevention and care. Despite being identified as at risk, no interventions were initiated, and documentation was inconsistent, leading to the ulcer's deterioration and infection.
A resident with a history of falls and muscle weakness fell multiple times due to the facility's failure to follow therapy recommendations and ensure proper transfer protocols. Despite therapy advising the use of a Hoyer lift, staff used a sit-to-stand lift without locking the bed wheels, resulting in a fall. The care plan lacked specific transfer instructions, and staff were unaware of the necessary protocols.
A resident with bilateral nephrostomy tubes did not receive appropriate incision care due to a lack of physician orders and inconsistent documentation. The resident's daughter raised concerns about the lack of dressing changes, which were supposed to occur every 3 to 7 days. Observations showed the bandages were in poor condition, and the facility's policies for wound care and physician orders were not followed.
A resident with severe cognitive impairment and multiple cancer diagnoses did not consistently receive the prescribed medication Xtandi due to unavailability. The facility's policy required notifying the physician and documenting missed doses, but there was no record of such actions. The DON noted the resident's wife was to supply the medication, which was unavailable as the resident was soon to be discharged.
Failure to Timely Assess and Follow Up on Lab Orders After Resident Change in Condition
Penalty
Summary
The facility failed to adequately assess a resident and follow up on provider lab orders in a timely manner after a change in condition. A resident with a history of atrial fibrillation, COPD, and dementia, who was on anticoagulant therapy, experienced a decline in condition over several weeks. Despite being at risk for bleeding, the resident was not assessed and charted on daily, and his condition was not closely monitored as required by his care plan. Orders for STAT labs were given after the resident exhibited symptoms such as weakness, moist breath sounds, and passage of black tarry stool, but there was no documentation that these labs were completed or that results were communicated to the provider in a timely manner. The resident's hemoglobin levels were critically low, with a significant drop noted in lab results, but there was a lack of documentation and follow-up regarding these abnormal findings. The contracted NP was not notified of the STAT lab results, and there was confusion among staff regarding lab orders and the process for reporting critical values. The facility's contracted lab did not process the STAT labs as required, and the results were not promptly reported to the facility or the provider. Additionally, there were gaps in documentation of the resident's assessments on multiple days when his condition warranted close monitoring. The DON acknowledged that nurses were responsible for documenting assessments and following up on lab results, but there was no specific facility policy for notifying providers of abnormal lab results. The lack of timely assessment, documentation, and provider notification led to a delay in recognizing the resident's deteriorating condition, ultimately resulting in the resident requiring hospitalization for a gastrointestinal bleed and blood transfusion.
Failure to Provide Timely Pressure Ulcer Prevention and Care
Penalty
Summary
A dependent resident with dementia and a recent right hip fracture, who required significant assistance with activities of daily living and was at risk for skin breakdown, was not provided timely and adequate care to prevent the development and worsening of a pressure ulcer. The resident was left in a recliner chair overnight, in the same clothes and position, without being repositioned or provided with incontinence care, despite being frequently incontinent of bladder and always incontinent of bowel. Staff documented that care was provided, but interviews revealed that no care or pressure prevention interventions were actually performed during the night shift, and the resident's refusal of care was not documented in the nurse notes for the relevant dates. The resident's family discovered the resident in soiled clothing and linens, with a sore on the left heel and dried blood on the sheets that had not been changed for three days. Upon assessment, a deep tissue injury (DTI) was identified on the resident's left heel, which progressed to an unstageable pressure ulcer with eschar and drainage. Observations showed that the heel protector was not consistently in place, and the ordered air mattress was not present on the resident's bed during multiple checks. The care plan and Braden Scale assessments indicated the resident was at risk for pressure ulcers, but appropriate interventions to prevent further skin breakdown were not implemented in a timely manner after the injury was identified. Facility policies required assessment and preventative interventions for residents at risk of pressure injuries, including offloading heels, repositioning, and use of pressure redistribution devices. However, these measures were not consistently followed for this resident, as evidenced by the lack of timely intervention, inconsistent use of protective devices, and failure to document or address care refusals. The delay in implementing physician-ordered treatments and pressure-relieving equipment contributed to the worsening of the resident's pressure ulcer.
Failure to Assess Change in Condition and Follow Provider Orders After Surgery
Penalty
Summary
A deficiency occurred when the facility failed to adequately assess a resident and follow provider orders after a change in condition following hip surgery. The resident, who had a history of left femur fracture, type 2 diabetes mellitus, and dementia, returned to the facility after surgical intervention for a hip fracture. On a specific date, the resident's leg was observed to be red, swollen, and warm, prompting a nurse practitioner to order a doppler ultrasound to rule out a blood clot. However, there was no evidence that this order was entered into the resident's medical record or the treatment administration record, nor was it referenced in progress or therapy notes in the days following the order. Despite the resident continuing to exhibit symptoms such as swelling, redness, and pain in the left leg over several days, there was no documentation of ongoing assessment, vital signs, or pedal pulse checks in the progress notes. The doppler ultrasound order was not processed in a timely manner, with delays in both entering the order into the resident's chart and submitting the request to the mobile ultrasound company. Staff interviews revealed confusion about the process for submitting urgent orders and uncertainty about the availability of the mobile ultrasound service on weekends. Communication lapses occurred, as nurses did not update the nurse practitioner about the resident's status or the lack of completion of the doppler study. The resident's condition deteriorated, and several days after the initial change in condition, the leg was found to be cold, deeply discolored, and pulseless. The resident was then sent to the hospital, where extensive blood clots were confirmed, and the resident was determined not to be a surgical candidate. The resident was admitted to inpatient hospice and subsequently passed away. The facility's failure to assess the resident's change in condition, document findings, and ensure timely completion of the ordered doppler study constituted the deficiency.
Failure to Assess and Report Change in Condition for Resident with Colostomy
Penalty
Summary
A deficiency occurred when the facility failed to assess and report a resident's change in condition to the physician, despite clear signs of clinical deterioration. The resident, who had a history of colostomy, recurrent small bowel obstructions, and congestive heart failure, began experiencing nausea, vomiting, and a lack of colostomy output over several days. Documentation showed that the resident had no stool in her colostomy bag for multiple days and was experiencing ongoing vomiting and weakness, but there was no timely notification to the physician or nurse practitioner regarding these symptoms. Staff interviews revealed that multiple qualified medication aides and LPNs were aware of the resident's symptoms, including vomiting and absence of colostomy output, but did not escalate the situation appropriately. One LPN, who was new to the facility, was unaware of the resident's history of small bowel obstructions and did not contact the on-call NP, instead leaving a note for the NP to review on the next business day. The care plan for the resident did not include specific monitoring for signs and symptoms of small bowel obstruction, such as nausea, vomiting, abdominal pain, or lack of colostomy output, despite the resident's medical history. The facility's policy required immediate notification of the physician and family in the event of a significant change in condition, but this was not followed. The resident's condition continued to deteriorate until she was eventually transported to the hospital, where she was diagnosed with a small bowel obstruction and subsequently passed away. The lack of timely assessment, documentation, and communication with the physician contributed to the deficiency cited in the report.
Failure to Report Missing Resident Medications as Required
Penalty
Summary
The facility failed to ensure that an allegation of missing medication was reported as required for one resident. The resident, who had diagnoses including a fractured femur, GERD, and gout, was admitted for short-term rehabilitation and brought his own supply of Nexium and Mitagare. During his stay, the resident's home medications were administered by staff, and upon discharge, the medications were placed in facility blue bags and left on the nurse's station desk for the resident to collect. The LPN responsible for discharge did not witness who picked up the bags, and the medications were subsequently reported missing by the resident after he returned home. The resident notified the facility about the missing medications, but the facility was unable to locate them. The resident then contacted the sheriff's department and filed a police report. The Administrator and DON became aware of the missing medications and the police involvement, but the Administrator acknowledged that the incident was not reported as required by facility policy. The facility's policy mandates immediate reporting of misappropriation of resident property, including contacting the police and following state-specific procedures, which was not followed in this case.
Failure to Reconcile and Securely Store Home Medications
Penalty
Summary
The facility failed to properly reconcile and securely store medications brought from home for two residents. One resident, admitted for short-term rehabilitation following a hip fracture, reported that staff would not provide his required medications unless he brought them from home. After arranging for his home medications to be delivered to the facility, the resident provided staff with Nexium and Mitagare, which were then administered to him. However, there was no documentation in the medical record regarding when these medications were brought in or the quantity supplied. Upon discharge, the resident was given two facility bags containing medications, but later discovered that two of his medications were missing and that he had been given a bag containing another resident's medications. The staff member responsible for the discharge indicated that the resident's medications had been stored in a secured medication cart and then placed in a blue bag for discharge. The nurse did not know when the medications were brought in or how much was present. The bags containing medications were left on the nurse's station desk, along with a third bag containing another resident's medications, which was to be picked up by a family member. The nurse was not present when the resident left and did not witness who took the bags. The resident later reported the missing medications to the sheriff's department. For the second resident, there was no documentation in the medical record or progress notes indicating that home medications had been brought in, administered, or returned upon discharge. The facility's policies required that medications brought from home be documented, securely stored, and returned to the resident or their family, but these procedures were not followed. Interviews with the administrator and assistant directors of nursing confirmed that medications should not have been left unsecured and that there was no documentation of the medications being returned or reconciled.
Failure to Report Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of abuse and injury of unknown origin for a resident with vascular dementia and other mental health conditions. An anonymous complaint was made to the Indiana Department of Health, alleging that the resident had been hit by a visitor and was found with a black eye the following day. On a specific date, a nurse progress note indicated that the resident had wandered into another resident's room and was hitting their visitor, who then grabbed the resident's shoulder to remove her from the room. Witness statements confirmed the incident, but there was no further documentation or reporting of the incident as required by the facility's policy. The following day, the resident was observed with a laceration above her right eye and a skin tear on her right hand, but she was unable to explain how the injuries occurred. A focused observation noted the resident's anxiety and additional injuries, yet there was no documentation indicating the incident had been reported or investigated. The facility's policy requires immediate reporting and investigation of such incidents, but the administrator confirmed that these incidents were not reported to her or the state agency as required.
Failure to Investigate Allegations of Abuse and Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse and injury of unknown source for two residents, Resident F and Resident G. An anonymous complaint was reported to the Indiana Department of Health, alleging that Resident F had been hit by a visitor and was found with a black eye the following day. Resident F, who resided in a secured memory care unit, had diagnoses including vascular dementia with agitation, delusional disorder, and major depressive disorder. She was noted to have severely impaired cognition and exhibited wandering behaviors. On 10/20/24, Resident F wandered into another resident's room and hit a visitor, who then grabbed her shoulders to remove her from the room. Witness statements were obtained, but there was no further documentation of an investigation into the incident or protection measures for Resident F. The report indicates that there was no documentation from 10/20/24 at 5:00 p.m. until 10/21/24 at 7:00 a.m. when a nurse noted Resident F had a laceration above her right eye and a skin tear on her right hand. The injuries were treated, but Resident F was unable to explain how they occurred. A focused head-to-toe observation noted bruising and a skin tear, but the psychiatric NP's progress note did not connect these injuries to the altercation with the visitor. The interdisciplinary note also failed to mention the altercation or investigate the injury's origin. Interviews with staff revealed that the altercation had not been reported to the ADON, and the facility's wound nurse was unaware of the incident. The facility's policy requires immediate investigation of all allegations of abuse and injuries of unknown source, but this was not followed. The Administrator acknowledged that both incidents should have been investigated immediately. The lack of documentation and investigation into the altercation and subsequent injuries to Resident F represents a failure to comply with the facility's abuse policy and to ensure resident safety.
Failure to Monitor and Assess Urinary Retention
Penalty
Summary
The facility failed to adequately monitor and assess a resident, identified as Resident E, for recurrent urinary retention, which contributed to a serious health condition. Resident E, who had diagnoses including dementia, COPD, and anxiety disorder, was noted to have severely impaired cognition and was dependent on staff for toileting. Despite a care plan in place to manage incontinence and prevent complications, there was a lack of documentation and follow-up regarding urinary retention observed on 8/6/24. The resident was found to have a distended abdomen and was straight cathed, removing 1000 milliliters of urine, yet there was no subsequent monitoring or assessment for urinary retention or its recurrence. The resident experienced intermittent episodes of anxiety, fast heart rate, and low oxygen levels, but the facility did not investigate the cause of urinary retention. Hospital records later indicated that Resident E was diagnosed with sepsis due to E. Coli bacteremia from a urinary tract infection and urinary retention. The facility lacked a policy for assessing and monitoring urinary retention, and documentation showed no urine output for 1 to 2 shifts on multiple days. The resident's daughter reported chronic issues with toileting and personal hygiene, which she believed contributed to the infection and subsequent death of her father.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide effective pressure ulcer care and prevention for Resident 243, who was admitted without skin impairment. Despite initial assessments indicating intact skin, subsequent records showed inconsistencies and omissions in monitoring and documenting skin conditions. A Braden Scale assessment identified Resident 243 as at risk for pressure ulcers, yet no interventions were implemented to prevent skin breakdown. Weekly skin assessments were incomplete, and skilled nursing notes lacked detailed wound assessments, leading to a deterioration of a facility-acquired skin impairment into a stage three pressure injury with infection. Resident 243's medical history included a traumatic brain injury, diabetes with polyneuropathy, and paresthesia, which increased his vulnerability to skin breakdown. Despite these risk factors, the facility did not develop a comprehensive care plan to address pressure relief for the resident's left elbow, where the pressure ulcer developed. The care plan was only initiated after the ulcer had progressed, and it included interventions such as using an air mattress and pressure-reducing cushions, which were not documented as being implemented in a timely manner. The facility's documentation and communication failures contributed to the inadequate care. There were gaps in nursing notes, missing wound assessments, and a lack of communication between CNAs and nursing staff regarding skin concerns. The facility's policies on skin and wound care were not followed, as evidenced by the lack of systematic skin inspections and the failure to implement evidence-based interventions promptly. These deficiencies resulted in the resident's pressure ulcer worsening and requiring antibiotic treatment for cellulitis.
Failure to Follow Transfer Protocols Leads to Resident Falls
Penalty
Summary
The facility failed to ensure proper interventions were followed to prevent falls for a resident, identified as Resident 22, who experienced multiple falls since admission. Resident 22, who had diagnoses including drug-induced polyneuropathy, repeated falls, unsteadiness on feet, and muscle weakness, reported falling three times within a month of admission. During a transfer using a sit-to-stand lift, the resident's knees gave out, and the bed moved away because the wheels were not locked, resulting in the resident being lowered to the floor. The care plan for Resident 22 indicated the bed should be kept in the lowest position with brakes locked, but it did not specify the use of a lift or the number of staff required for transfers. Interviews and record reviews revealed that therapy staff had recommended using a Hoyer lift for transfers, and this recommendation was not followed by the nursing staff. A therapy note indicated that the resident had limited standing tolerance, and a physician's order allowed the use of a Hoyer lift when fatigue was present. However, the CNA involved in the transfer was unaware of the care plan details and the Kardex, which should have directed staff care. The DON confirmed that therapy recommendations should be followed and that the bed should have been locked prior to the transfer. The facility's Mechanical Lift Policy required transfer status to be determined upon admission and as needed, based on nursing judgment or therapy recommendation, which was not adhered to in this case.
Failure to Provide Nephrostomy Care
Penalty
Summary
The facility failed to provide appropriate nephrostomy incision care for Resident Z, who was admitted with bilateral nephrostomy tubes due to multiple health conditions, including prostate cancer, bladder cancer, and end-stage kidney disease. Upon review, it was found that Resident Z's nephrostomy dressing had not been changed since admission, and there were no physician orders for nephrostomy tube site care. The resident's care plan did not include instructions for dressing changes, and the Director of Nursing (DON) was unaware of the nephrostomy care needs due to being new to the facility. Observations and interviews revealed inconsistencies in the documentation and care provided to Resident Z. Skilled Nursing Notes indicated conflicting information about the presence of a urinary catheter and surgical incisions. The resident's daughter expressed concerns about the nephrostomy tube being displaced and the lack of dressing changes, which were supposed to occur every 3 to 7 days as per hospital instructions. The facility's policy required wounds to be assessed and dressings applied as ordered by a physician, but this was not followed. The facility's failure to ensure proper nephrostomy care was further highlighted by the condition of the bandages observed during inspections. The right nephrostomy tube bandage was missing a portion of its covering, and the left bandage was creased and illegible. The facility's policies required reviewing all referring facility information to determine appropriate admission orders and contacting the physician for additional orders based on medical treatment needs, which was not adequately executed in this case.
Failure to Provide Prescribed Medication
Penalty
Summary
The facility failed to ensure that a prescribed medication, Xtandi, was consistently provided to a resident diagnosed with bone cancer, prostate cancer, and bladder cancer. On a specific date, an LPN was observed unable to locate the medication in the medication cart or the facility's medication dispensary machine. The resident's Medication Administration Record (MAR) indicated that Xtandi was not administered on several occasions due to the medication being on order or unavailable, and there was no documentation of notification to the pharmacy or the prescribing physician about the unavailability of the medication. The Director of Nursing (DON) indicated that the resident's wife was responsible for supplying the medication to the facility and that the medication was unavailable on the day of the observation because the resident was to be discharged soon. The facility's policy required notifying the resident's physician if a medication was unavailable and documenting the circumstances of any missed doses in the MAR and progress notes. However, the progress notes did not reflect any notification to the pharmacy or physician regarding the unavailability of Xtandi.
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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