Hamilton Grove
Inspection history, citations, penalties and survey trends for this long-term care facility in New Carlisle, Indiana.
- Location
- 31869 Chicago Trail, New Carlisle, Indiana 46552
- CMS Provider Number
- 155672
- Inspections on file
- 26
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Hamilton Grove during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was discharged home, but the responsible party was not provided with the required written Notice of Medicare Non-Coverage or bed-hold information. Although the resident received and signed the NOMNC, staff confirmed that the responsible party, who was designated as the resident's representative, did not receive these notifications, and the facility could not produce the relevant policy when requested.
A resident with multiple chronic conditions was discharged without a documented discharge care plan, and the responsible party was not invited to participate in care planning meetings. Despite facility policy requiring involvement of the resident and their representative, neither were included in the discharge planning process.
The facility did not notify a physician of changes in condition and missed or refused medication doses for two residents with complex medical histories. One resident missed several scheduled medications without documentation or physician notification, while another experienced a low blood pressure reading that was not reported to the medical provider or family, contrary to facility policy.
Two residents receiving antipsychotic medications did not receive required quarterly AIMS assessments as per facility policy. One resident with multiple psychiatric and medical diagnoses had not had an AIMS assessment for several months, and another resident with a psychotic disorder had only one AIMS assessment documented in the past year, despite daily antipsychotic use. The DON confirmed that the facility's policy for quarterly monitoring was not followed.
Surveyors found that the facility did not consistently label, date, or dispose of opened and expired food items in the kitchen. During inspection, multiple food products were observed either expired or lacking required dates, and the CDM confirmed that opened foods should be dated and used within three days. The facility's policy also required proper labeling and timely disposal, but these procedures were not followed, potentially affecting all residents receiving meals.
Surveyors observed that a resident's personal refrigerator contained multiple expired and spoiled food items, including undated juice with visible spoilage and a bowl of moldy, unidentifiable food. Staff interviews revealed uncertainty about who was responsible for cleaning out personal refrigerators, despite facility policy requiring proper labeling, dating, and disposal of stored food.
The facility failed to accurately transcribe and administer medications for two residents. One resident with heart failure did not receive Lasix as ordered, and a vitamin supplement was not administered correctly. Another resident with multiple diagnoses missed several medication doses due to a lack of coordination between the facility and pharmacy, and failure to notify the physician of missed doses.
A resident with multiple sclerosis and impaired mobility developed unstageable pressure ulcers on both heels due to the facility's failure to implement and monitor necessary interventions. Despite being at moderate risk, the resident's condition deteriorated, with inconsistent documentation and lack of communication among staff contributing to the issue.
The facility failed to develop person-centered care plans for four residents, leading to inadequate management of activities, behaviors, ADLs, and dementia care. Observations and interviews confirmed that the care plans were not tailored to the residents' specific needs.
A facility failed to provide adequate ADL care for a resident dependent on staff for bathing, hygiene, and dressing. Observations showed the resident was not shaved and had long, dirty fingernails. The care plan lacked documentation on the resident's refusal of care, and staff interviews confirmed no proper plan was in place to address these refusals.
The facility failed to provide adequate activities for three residents, leaving them unengaged and unsupported in their physical, mental, and psychosocial well-being. Observations showed residents sitting alone without activities, and care plans were not person-centered or effectively implemented.
The facility failed to secure a resident's cigarettes at the Nurse's Station, despite a care plan and facility policy requiring smoking materials to be kept by staff. The resident was found with smoking materials in his room on multiple occasions, and staff interviews confirmed that the cigarettes should have been secured.
The facility failed to prevent a resident with severe cognitive impairment from wandering into other residents' rooms. Despite interventions like Velcro STOP signs and a wandergard, the resident continued to enter rooms, causing frustration among other residents. Staff were often unaware of the resident's location and had to manually redirect her.
The facility failed to ensure shift narcotic count sheets were completed and documented every shift for one of the two narcotic books observed. Missing signatures indicated that narcotics were not counted every shift, contrary to the facility's policy.
The facility failed to ensure that a resident receiving an opioid and an anti-anxiety medication had appropriate indications and was monitored for adverse side effects. The resident's records lacked documentation for why the medications were given and did not show any nonpharmacological interventions tried prior to administering the medications. The ADON confirmed that the medications should not have been given together and that proper documentation and assessment were not followed.
The facility failed to remove expired medications from the medication cart and did not adequately monitor the medication refrigerator's temperature, leading to a large build-up of ice. Interviews with RNs confirmed these lapses, and a policy on these procedures was not provided before the survey exit.
The facility failed to ensure proper catheter orders and care for a resident with severe cognitive impairment and an indwelling catheter. There were no physician's orders for the catheter, and intake and output were not consistently documented as required. The facility's Catheter Care Policy was not followed, and the Director of Nursing confirmed the deficiency.
Failure to Notify Responsible Party of Medicare Non-Coverage and Bed-Hold Policy
Penalty
Summary
The facility failed to provide the required written Notice of Medicare Non-Coverage (NOMNC) to the responsible party for a resident who was discharged home with family. The resident, who had multiple diagnoses including a fractured sacrum, chronic bronchitis, COPD, repeated falls, altered mental status, depression, anxiety, and liver cancer, was admitted and later discharged from the facility. Documentation showed that the resident was cognitively intact and required varying levels of assistance with activities of daily living. The resident participated in care planning and expressed a goal to return home, but the responsible party did not participate in the care plan meeting. Record review and staff interviews confirmed that while the resident personally received and signed the NOMNC form, the responsible party—identified in the admission agreement as the resident's representative—was not provided with the NOMNC or any bed-hold information as required by facility policy. The DON and Administrator both acknowledged that the responsible party had not been sent the necessary notifications. Additionally, when requested, the facility was unable to provide a policy for Admission, Transfer, and Discharge.
Failure to Develop Discharge Care Plan and Involve Resident Representative
Penalty
Summary
The facility failed to develop and implement a discharge care plan for one resident who was reviewed for discharge planning. The resident, who had multiple diagnoses including a fractured sacrum, chronic bronchitis, COPD, repeated falls, altered mental status, depression, anxiety, and liver cancer, was admitted and later discharged home with family. Although the resident was cognitively intact and participated in therapies and goal setting for discharge, there was no evidence that a discharge care plan was created or included in the comprehensive care plan. Additionally, the discharge assessment did not indicate involvement of the resident or the resident's responsible party in the discharge planning process. The facility also did not ensure that the resident's responsible party, who was identified as the resident's representative in the admission agreement, was invited to participate in care planning meetings. Interviews with the DON and Administrator confirmed that neither the resident's family nor responsible party were provided invitations or notifications for care plan meetings, despite facility policy requiring their involvement. Documentation showed that the resident was notified of Medicare non-coverage and signed the appropriate form, but this did not substitute for the required discharge planning and involvement of the resident's representative.
Failure to Notify Physician of Change in Condition and Missed Medications
Penalty
Summary
The facility failed to notify a physician of changes in condition and missed medication doses for two residents. For one resident with multiple diagnoses including dementia, depression, anxiety, and cardiovascular conditions, the Medication Administration Record showed missed and refused doses of olanzapine, melatonin, and pravastatin on several dates. There was no documentation explaining why the medications were not administered on one occasion, nor any evidence that the physician was notified of the refusals or missed doses. The Assistant Director of Nursing confirmed the lack of documentation and was unable to determine why the medications were not given or if the physician had been informed. For another resident with diagnoses such as vascular dementia, chronic kidney disease, and a history of cerebrovascular events, a nursing progress note documented a low blood pressure reading. The clinical record did not show that the medical provider or family was notified of this low blood pressure. Interviews with nursing staff and the Director of Nursing confirmed that the nurse should have re-checked the blood pressure and notified the physician, but there was no evidence this occurred. Facility policies required notification of physicians and families for acute condition changes and documentation of medication refusals, which was not followed in these cases.
Failure to Perform Required Quarterly AIMS Assessments for Residents on Antipsychotics
Penalty
Summary
The facility failed to ensure adequate monitoring of antipsychotic medications for two residents who were prescribed these drugs. For one resident with diagnoses including dementia, major depressive disorder, and generalized anxiety disorder, the record showed that an Abnormal Involuntary Movement Scale (AIMS) assessment was last completed on 12/2/2024, with no further documentation of quarterly assessments as required by facility policy. The Director of Nursing confirmed that the resident had not received the required quarterly AIMS assessments while on olanzapine. For another resident with psychotic disorder with delusions and major depressive disorder, documentation revealed that only one AIMS assessment was completed in the past year, despite the resident receiving daily antipsychotic medication and the care plan specifying quarterly AIMS assessments. The DON acknowledged that the required quarterly assessments had not been performed for this resident in 2024. The facility's policy mandates AIMS assessments on admission, quarterly, with changes in condition or medication, or as needed, but this was not followed for these two residents.
Failure to Properly Label, Date, and Dispose of Opened and Expired Food Items
Penalty
Summary
Surveyors observed that the facility failed to store food in a sanitary manner in the kitchen, specifically regarding the labeling, dating, and disposal of opened and expired food items. During a kitchen inspection with the Certified Dietary Manager (CDM), several food items in the walk-in cooler, such as smoked turkey, cut up purple and white onions, premade chicken salad, and Virginia ham, were found either expired or lacking an opened on or use by date. Additionally, other items including leaf tarragon, ranch powder, red food coloring, and chopped chives were found open without proper labeling or had expired. The CDM confirmed during an interview that all opened food should be dated with the day it was opened and used within three days or discarded. The facility's policy, as provided by the Administrator, required all foods to be properly labeled and dated, and for prepared or opened food items to be discarded if left over for more than 72 hours. These observations and interviews demonstrated that the facility did not consistently follow its own food storage and labeling policies, potentially affecting all residents who received meals from the kitchen.
Expired and Spoiled Food Found in Resident's Personal Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary environment by not properly disposing of expired food in a resident's personal refrigerator. During an observation, surveyors found multiple expired food items, including a container of parmesan cheese, single-serve cups of chocolate and vanilla pudding, and two cups of juice with no dates, both of which showed signs of spoilage such as separation and a thick white substance. Additionally, a bowl with a lid contained unidentifiable, moldy food with no date. When interviewed, an RN was unsure who was responsible for cleaning out residents' personal refrigerators, while the DON stated it was the nurse's responsibility. The facility's policy required food to be labeled, dated, and discarded per safe food storage guidelines, but this was not followed in this instance.
Medication Administration Failures for Two Residents
Penalty
Summary
The facility failed to ensure accurate transcription and timely administration of medication and supplement orders for two residents. Resident C, who had diagnoses including chronic obstructive pulmonary disease and heart failure, had a physician's order to increase Lasix to 80 mg per day. However, the medication was only administered twice over a period of more than a month. Additionally, an order to increase Occuvite to twice daily was not properly transcribed, resulting in it being administered only once daily. The Assistant Director of Nursing (ADON) acknowledged that there was no system in place to audit new physician orders for accuracy and timeliness until September, when the Interdisciplinary Team (IDT) began reviewing new orders during morning meetings. Resident J, diagnosed with multiple sclerosis, cerebral palsy, and seizures, did not receive several medications as ordered upon admission. The facility's pharmacy did not send medications because they were informed that the resident had brought his own supply, and the nursing staff directed the pharmacy not to send additional medications. Despite this, there were no nursing notes indicating that the physician was notified of the missed doses. The facility's policy required a second nurse to review transcribed orders for accuracy, but this process was not followed, leading to multiple missed doses of critical medications.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of unstageable pressure ulcers and did not provide necessary treatment and services to promote healing and prevent infection for a resident who was admitted without pressure ulcers. The resident, who had multiple sclerosis, edema, neuropathy, and hypertension, was at risk for pressure ulcers due to impaired mobility and required substantial staff assistance. Despite being identified as at moderate risk for pressure ulcers, the resident developed deep tissue injuries on both heels, which deteriorated into more severe pressure injuries. The facility's care plan for the resident included interventions such as daily skin observation, Braden Scale assessments, heel protectors, and moisturizing the heels. However, these measures were not effectively implemented or monitored. The resident's pressure ulcers were not promptly assessed or documented, and there was a lack of communication and coordination among the nursing staff, nurse practitioners, and wound care specialists. The facility also failed to provide complete pressure relief to the resident's heels, both in bed and out of bed, and did not adequately address the resident's refusal to wear pressure-relieving boots. The facility's documentation was inconsistent and incomplete, with missing assessments and evaluations of the resident's pressure ulcers. The nursing staff continued to document outdated treatments, and there was no evidence of timely wound culture results or appropriate adjustments to the care plan. The facility's failure to monitor and evaluate the impact of interventions, as well as revise them as necessary, contributed to the deterioration of the resident's condition and the development of additional pressure ulcers.
Failure to Develop Person-Centered Care Plans
Penalty
Summary
The facility failed to develop person-centered care plans for activities, behaviors, ADLs, and dementia care for four residents. Resident 25 was observed not participating in activities and was often found in bed. Her care plan did not reflect her preferences and needs, as she had severe cognitive impairment and exhibited delusions and physical behaviors. Despite interventions like providing reading material and one-on-one interactions, the care plan was not effective, and the Activity Director confirmed it was not person-centered. Nurses' notes indicated frequent episodes of yelling and confusion, which were not adequately addressed in the care plan. Resident 23 had a care plan that did not adequately address his dementia and behavior disturbances. The care plan included general interventions like calling the resident by his preferred name and keeping routines consistent, but it was not tailored to his specific needs. The Infection Prevention Nurse confirmed that the care plan was not person-centered. Resident 36 was observed with poor personal hygiene, including unshaved facial hair and dirty fingernails. His care plan did not document his refusal of ADLs, and the ADON confirmed that there should have been a care plan addressing his refusals. Resident 53's care plan also lacked person-centered interventions for her severe cognitive impairment. The Assistant Director of Nursing confirmed that the care plan was not person-centered. The facility's policy on comprehensive care plans emphasized person-centered care, but this was not reflected in the care plans reviewed.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADLs) care for a resident who was dependent on staff for bathing, hygiene, and dressing. Observations on two separate occasions revealed that the resident had not been shaved and had long fingernails with brownish-yellow matter under them. The resident's care plan indicated that he had issues with ADLs due to impaired cognition, decreased mobility, incontinence, generalized weakness, and medication use. However, the care plan lacked documentation regarding the resident's occasional refusal of shaving and nail care. Interviews with staff confirmed that the resident often refused these aspects of care, but there was no care plan in place to address these refusals, and the aide report sheet did not indicate what actions to take if the resident refused ADL care. The Assistant Director of Nursing (ADON) confirmed that there was no care plan for the resident's refusal of ADLs and that aides should report refusals to the nurse, who would then document it in interdisciplinary notes. The facility's policy on ADLs, dated 1/23/2024, stated that care and services would be provided for bathing, dressing, grooming, and oral care, but this policy was not effectively implemented for the resident in question. The lack of documentation and appropriate care planning led to the deficiency in providing necessary ADL care for the resident.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide activities that support the physical, mental, and psychosocial well-being of each resident for three of the four residents reviewed. Resident 36 was observed multiple times sitting in the common area without engaging in any activities. Despite the activity aide's announcements, no activities were conducted, and the resident was left unengaged. The resident's care plan indicated a need for assistance with activities and a preference for sports on TV, but these preferences were not met consistently. The Activity Director acknowledged the need for more activities on the Center Unit and identified issues with transporting dementia residents to activities. Resident 25 was observed sleeping in her room during multiple observations and did not participate in scheduled activities. The resident's care plan indicated a preference for staying in her room and engaging in activities like watching TV, reading, and working on puzzles. However, the care plans were not person-centered, and the resident's participation in activities was minimal. The Activity Director admitted that the care plans did not have effective interventions for the resident. Resident 53 was observed sitting alone and unengaged during multiple observations. The resident's care plan lacked documentation of activity refusals and did not include an Activities Care Plan. The resident participated in a limited number of activities in March and April. Staff interviews revealed that the resident was not consistently invited to activities, and one-on-one interactions were infrequent. The Activities Director confirmed that the facility did not have a process to document activity invitations and refusals, and the resident did not participate in many activities during the observed months.
Failure to Secure Resident's Cigarettes
Penalty
Summary
The facility failed to secure a resident's cigarettes at the Nurse's Station for a resident who was reviewed for smoking. During an observation, the resident was found with an ashtray containing ashes, cigarette butts, and cigarettes in his room, despite a care plan indicating that smoking materials should be kept at the Nurse's Station. The resident's record review revealed multiple diagnoses, including cerebral infarction, hemiplegia, generalized anxiety, and vascular dementia. The care plan also noted that the resident had a history of selling cigarettes to Assisted Living Residents and required supervision for smoking. Despite these interventions, the resident was observed with smoking materials in his room on multiple occasions, and staff interviews confirmed that the cigarettes should have been secured at the Nurse's Station. During a random observation, a housekeeper, who was also the resident's sister, was seen taking the resident outside to smoke and was unaware that the cigarettes should not be in the resident's room. Interviews with the CNA, RN, and DON confirmed that the resident should not have had smoking materials in his room. The facility's Smoking Policy, provided by the DON, indicated that all smoking materials should be maintained by activities staff during the day and nursing staff after 5 PM and on weekends. The policy also required residents and family members to turn in smoking materials after smoking. Despite these policies, the resident's cigarettes were not properly secured, leading to the deficiency.
Failure to Prevent Wandering of Resident with Dementia
Penalty
Summary
The facility failed to prevent a resident with dementia from wandering into other residents' rooms. Resident 53, who has severe cognitive impairment and a history of wandering due to Alzheimer's Disease and dementia, was observed entering other residents' rooms multiple times. Interviews with other residents revealed that Resident 53 often took their belongings, which were always returned, but caused frustration and inconvenience. Staff interviews indicated that the interventions listed in Resident 53's care plan, such as Velcro STOP signs, were ineffective, and staff had to manually redirect the resident by taking her hand and leading her elsewhere. The care plan also included the use of a wandergard and providing a hazard-free environment, but these measures did not prevent the resident from wandering into other rooms. During observations, Resident 53 was seen entering various rooms, including during an interview with another resident by a State Surveyor. Staff, including RN 7 and CNA 9, were often unaware of Resident 53's location and had to escort her out of other residents' rooms. The Director of Nursing (DON) acknowledged that the current interventions were ineffective and stated that the staff would work to find better solutions. The facility's policies on elopement and dementia care emphasized the need for adequate supervision and individualized, non-pharmacological approaches, but these were not effectively implemented for Resident 53.
Failure to Complete and Document Shift Narcotic Counts
Penalty
Summary
The facility failed to ensure that shift narcotic count sheets were completed and documented every shift for one of the two narcotic books observed in the West Hall. During a medication storage observation, it was found that the narcotic sheets dated from January 12, 2024, to April 8, 2024, had missing signatures, indicating that narcotics were not counted every shift. Specifically, there were seven missing signatures for the day shift and twenty-six missing signatures for the evening and night shifts. RN 11 confirmed that narcotics should be counted every shift and documented on the sheet. The Director of Nursing provided the current policy, which mandates a 24-hour recording of controlled substance use, but the facility did not adhere to this policy.
Failure to Monitor and Document Medication Administration
Penalty
Summary
The facility failed to ensure that a resident who received an opioid and an anti-anxiety medication had an appropriate indication and was monitored for adverse side effects. Resident 7, who had diagnoses including dementia, depression, anxiety, and osteoarthritis, was observed multiple times either yelling or sleeping in her wheelchair. The resident's Medication Administration Record (MAR) indicated that she received Lorazepam and Morphine 10 times on the same dates and times, but the clinical record lacked documentation for why the medications were given. Additionally, there was no documentation of any nonpharmacological interventions tried prior to administering the medications. The Assistant Director of Nursing (ADON) confirmed that the medications should not have been given together and that nonpharmacological interventions should have been tried first. The ADON also indicated that a pain scale should have been documented when giving Morphine, and the resident should have been assessed for pain and documented on the chart. The facility's policies on pain management and unnecessary drugs were not followed, as there was no reassessment or documentation of the effectiveness of the medications or monitoring for adverse side effects such as itching.
Expired Medications and Inadequate Temperature Monitoring
Penalty
Summary
The facility failed to ensure expired medications were removed from the medication cart and did not adequately monitor the medication refrigerator's temperature. During an observation, an opened bottle of lactulose liquid and two opened bottles of Guafenesin syrup were found on the medication cart, all of which had expired. Additionally, the medication refrigerator had a large build-up of ice, and temperature logs showed numerous instances of missing documentation for both AM and PM temperatures. Interviews with the responsible RNs confirmed that the expired medications should have been removed and that temperatures should be documented twice daily. A policy on these procedures was requested but not provided before the survey exit.
Failure to Ensure Proper Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure proper catheter orders and catheter care for a resident with a catheter, and did not consistently document intake and output as ordered. Resident B, who had severe cognitive impairment and was dependent on others for all Activities of Daily Living, had an indwelling catheter for urinary retention. Despite the resident's condition and the presence of a catheter, there were no physician's orders regarding the Foley catheter or its care. Additionally, the Treatment Records from December 1, 2023, to January 30, 2024, lacked documentation of catheter care and intake and output measurements as required by the physician's orders. The resident's care plan indicated that the catheter should be changed as ordered by the physician, maintain a closed drainage system, and record intake and output in the medical record. However, there were multiple instances where intake and output were not documented across various shifts in December 2023 and January 2024. The facility's Catheter Care Policy, which mandates catheter care every shift and as needed, was not followed. The Director of Nursing confirmed that catheter orders and care should be documented in the facility's physician's orders and completed per order and facility policy.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
