Hooverwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 7001 Hoover Rd, Indianapolis, Indiana 46260
- CMS Provider Number
- 155001
- Inspections on file
- 38
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Hooverwood during CMS and state inspections, most recent first.
A resident with dementia and a history of wandering exited a secured unit unsupervised by passing through an unlocked stairway and an unlocked, alarmed exit door. Staff reset the alarm without investigating, and the resident was later found outside the facility by a CNA. The care plan and elopement policy did not include updated interventions or clear staff response procedures for door alarms, contributing to the resident's unsupervised exit.
A resident who was fully dependent on staff for toileting and hygiene was left without incontinence care for an entire shift. The resident was found sitting in a recliner with saturated clothing and furniture, and no care or documentation was provided by the assigned CNA during the shift, despite facility policies requiring regular checks and assistance.
A nurse repeatedly signed out and documented the administration of Norco, a narcotic pain medication, for a resident who did not actually receive the medication during daytime hours. The resident, who was alert and cognitively intact, reported only taking the medication at night, and the MAR did not show daytime administrations. Facility policies required proper documentation and narcotic counts, but these were not followed, resulting in the misappropriation of the resident's medication.
Two residents were found with medications at their bedside without required self-administration assessments by the IDT, as confirmed by an LPN and Unit Manager. Both residents had multiple diagnoses, and facility policy mandates such evaluations before allowing self-administration of medications.
A resident with severe cognitive impairment was repeatedly observed with her breast exposed in a public area, and on another occasion, was left in soiled incontinence briefs for an extended period, resulting in discomfort and odor. Nursing leadership and staff acknowledged the need for closer monitoring and adherence to policies requiring regular checks and prompt hygiene care.
A dependent resident with severe cognitive impairment and blindness was transferred using a sit-to-stand mechanical lift without a prior safety evaluation, despite her inability to participate in the transfer as required. Staff used the lift contrary to the care plan and facility policy, and the resident did not hold the handlebars, resulting in an unsafe transfer that required physical assistance to complete.
The facility did not ensure that a licensed pharmacist completed required monthly drug regimen reviews for several residents receiving psychoactive medications, resulting in missing documentation for multiple months. The DON confirmed that pharmacy reviews were not available for certain periods, particularly during a change in pharmacy providers, despite facility policy requiring regular review.
A resident who required set-up assistance for meals was repeatedly left asleep with meal trays delivered to her room, resulting in food cooling to unsafe and unappetizing temperatures. Despite the resident's stated preference to be awakened for meals, staff did not consistently do so, and her care plan lacked documentation of her meal delivery preferences. Food temperature checks confirmed that meals were served below required standards, and other residents also reported receiving cold food in their rooms.
Two residents reported being treated without respect and dignity by CNAs. One resident felt hurt by a CNA's rough and grouchy behavior, while another resident reported being yelled at and scolded by a different CNA. Both residents had significant medical histories and were unable to be interviewed during the survey.
A resident with multiple health conditions fell during a Hoyer lift transfer when a CNA attempted the procedure alone, contrary to facility policy requiring two staff members. The resident moved her hands, slid out of the lift, and was repositioned onto the floor, resulting in pain and the need for medication.
A facility failed to properly administer and document narcotic medications for two residents. An agency nurse, RN 10, did not document the administration of prescribed narcotics in the EMAR, despite signing them out on the narcotic sheet. Resident C's and Resident D's records showed discrepancies, with Resident D reporting only receiving Tylenol instead of Oxycodone. Resident H also had missing documentation for Oxycodone. The facility's policy required accurate documentation, which was not followed, leading to a deficiency in pharmaceutical services.
A resident with severe cognitive impairment was sexually assaulted by a contracted housekeeper in the dementia unit. The housekeeper was found on top of the resident with his pants down, while the resident's gown and brief were open. The resident, who required maximum assistance with personal care and had a self-care performance deficit, was unable to communicate effectively due to her condition and language barrier. The incident highlighted a failure in the facility's protective measures.
A resident with dementia was physically abused by a staff member who pulled the resident by the ears, causing redness. The incident was witnessed by another staff member who reported it to the DON. The resident's medical history included dementia and other conditions. The facility's policy on abuse was violated.
The facility failed to protect the personal property and financial assets of two residents. One resident's AirPods were stolen and pinged to a CNA's address, leading to her termination. Another resident's credit card was used without permission for a restaurant purchase, despite her inability to leave the facility independently. These incidents highlight lapses in securing residents' belongings and preventing unauthorized access by staff.
A privacy breach occurred when a resident's medication list was incorrectly sent to a hospital, leading to a delay in medication administration. Two LPNs were involved in preparing the resident for transfer, and an error was made when the medication list for another resident was included in the envelope. The mistake was discovered by the resident's niece, who reported it to the hospital staff, prompting the facility to send the correct information.
Failure to Prevent Elopement of Resident with Dementia and Wandering Behaviors
Penalty
Summary
A resident with dementia, severe cognitive impairment, and a known history of wandering and exit-seeking behaviors exited the facility unsupervised despite being on a secured locked unit and wearing a wanderguard device. The resident was able to leave the secured unit through an unlocked stairway door, descend to the first floor, and exit the building through an unlocked but alarmed door. The stairway door was supposed to be locked and checked daily by the Maintenance Director, but it was not checked on the day of the incident. The exit door alarm sounded, but staff reset the alarm without investigating the cause or checking outside, and the resident was not immediately located. The resident wandered approximately 0.4 miles away from the facility, crossing a two-lane road before being found by a CNA walking in the grass along the road. The resident's care plan and assessments documented her high risk for elopement, use of a wanderguard, and previous incidents of exit-seeking, including a prior event where she left the building and required intervention. Despite these documented risks and behaviors, there were no updated interventions in the care plan after the previous elopement incident, and the facility's elopement policy did not specify staff response to door alarms. Interviews and record reviews revealed that staff were not aware of the resident's exit until a code for a missing resident was called, and the alarmed door had been tampered with, preventing it from locking properly. Staff responding to the alarm did not open the door or check the area outside, and only later realized the resident was missing. The resident was eventually found without injury, but the incident demonstrated a failure to ensure the environment was free from accident hazards and that adequate supervision and monitoring were provided to prevent accidents for residents at risk of elopement.
Failure to Provide Incontinence Care Resulting in Resident Neglect
Penalty
Summary
A dependent resident with a history of cerebral infarction, dementia, and type 2 diabetes mellitus was not provided incontinence care during an entire eight-hour shift. The resident was totally dependent on staff for toileting and hygiene, requiring a stand lift and assistance from two staff members. According to the care plan, peri-care was to be completed with each incontinence episode. However, documentation and interviews revealed that the assigned CNA did not provide or document any toileting or incontinence care for the resident during the shift. When the resident's daughter visited, she found the resident sitting in a recliner with a strong odor of urine and feces, and both the resident's clothing and recliner were saturated. The incontinence brief was so saturated it fell to the resident's knees when she was assisted to stand. The facility's point of care documentation confirmed that no toileting or incontinence care was recorded for the resident during the CNA's shift. The CNA later admitted to neglecting her duties during this period. The facility's policies and the CNA's job description required regular checks, assistance with toileting and incontinence needs, and proper documentation of care provided. These requirements were not met, resulting in the resident being left in soiled clothing and furniture for an extended period.
Misappropriation of Resident's Narcotic Medication by Staff
Penalty
Summary
A deficiency occurred when a nurse (RN) repeatedly signed out and documented the administration of Norco, a narcotic pain medication, for a resident who did not actually receive the medication. The resident, who was cognitively intact, alert, oriented, and a retired RN, consistently reported that she only took Norco at night to help her sleep and never during the day. Despite this, the narcotic count sheets showed that the RN signed out Norco for the resident on multiple occasions during daytime hours, often one tablet at a time, while the resident's order was for two tablets every six hours as needed for pain. The Medication Administration Record (MAR) did not reflect these daytime administrations, and the resident confirmed she had not received the medication during those times. Interviews with staff, including the DON and other nurses, confirmed that the facility's policy required all administered medications, especially PRN narcotics, to be documented both on the narcotic sheet and in the electronic MAR. If a medication was not documented in the MAR, it was considered not administered. The discrepancy was identified when another nurse noticed inconsistencies between the narcotic count sheet, the resident's order, and the MAR. The resident was able to identify her medications and was aware of what she had taken, further supporting that the narcotics were not administered as documented by the RN. The facility's policies also required a narcotic count at each shift change, with both off-going and on-coming nurses signing the count sheet. Despite these procedures, the RN continued to sign out and document the removal of Norco without actual administration to the resident, resulting in the misappropriation of the resident's medication. The resident's rights policy specifically stated that residents have the right to be free from misappropriation of property, which was not upheld in this instance.
Failure to Complete Self-Administration Medication Assessments
Penalty
Summary
The facility failed to ensure that residents who self-administer medications had appropriate assessments completed by the interdisciplinary team. Specifically, two residents were observed with medications, including Afrin nasal spray, lubricant eye drops, and diclofenac/lidocaine cream, on their bedside tables. Review of their clinical records revealed that neither resident had a documented self-administration evaluation by the interdisciplinary team, as required by facility policy. Interviews with an LPN and a Unit Manager confirmed that these residents should have had self-administration evaluations in their records if they were keeping medications in their rooms. The facility's policy states that residents wishing to self-administer medications must be assessed by nursing staff, with the assessment reviewed by the IDT and physician before approval. Both residents had multiple diagnoses, including hypertension, cataracts, diabetes, and pain, but lacked the necessary documentation to support self-administration of their medications.
Failure to Maintain Resident Dignity and Provide Timely Incontinence Care
Penalty
Summary
Staff failed to ensure a dependent resident with dementia and severe cognitive impairment was dressed appropriately to maintain her dignity and provided with timely incontinence care. On two separate occasions, the resident was observed sitting in a lounge area with her shirt pulled up, exposing her left breast. In both instances, nursing leadership noticed the exposure and adjusted the resident's clothing. Interviews with the Assistant Director of Nursing and Director of Nursing confirmed awareness of the issue and the need for closer monitoring. Additionally, the resident was observed sitting in the lounge for an extended period with bath blankets wrapped around her, emitting a strong odor of urine and bowel movement. The resident was visibly uncomfortable, leaning to one side. After being informed, the Unit Manager and a CNA provided care, finding the resident's brief soaked with urine and a large loose bowel movement. Staff interviews and facility policy confirmed that residents should be checked and changed at least every two hours or as needed, and that perineal care should be performed after episodes of incontinence to maintain cleanliness and comfort.
Failure to Evaluate and Safely Transfer Dependent Resident Using Mechanical Lift
Penalty
Summary
A dependent resident with severe cognitive impairment, dementia, and blindness was transferred using a sit-to-stand mechanical lift without a prior evaluation to ensure the transfer method was safe for her condition. During the transfer, the resident did not hold onto the handlebars as instructed, and the sling strap slipped under her armpits while she was not using her legs to stand. The transfer was completed with staff physically assisting the resident to the bed, despite the resident's refusal and inability to participate as required for safe use of the lift. The resident's care plan indicated total dependence and the need for assistance by two staff members for transfers, but did not specify the use of a sit-to-stand lift. There was no documentation of a safety evaluation for the use of this lift with the resident. Staff interviews confirmed that the assignment sheet was incorrect and that the sit-to-stand lift was not an appropriate transfer method for this resident. Facility policy required checking assignment sheets for approved transfer methods and ensuring residents could safely use mechanical lifts, which was not followed in this instance.
Failure to Ensure Monthly Pharmacist Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly drug regimen reviews, including review of the medical chart, for several residents as required. For one resident with diagnoses including Alzheimer's disease, psychotic disorder, severe kidney disease, diabetes, depression, and anxiety, pharmacy reviews were missing for July, with no documentation found for that month despite a change in pharmacy providers. The DON confirmed that neither the current nor previous pharmacy provider could produce the missing review. Another resident with seizure disorder, anxiety, and depression had missing pharmacy reviews for multiple months, including June, July, January, and February, with the DON confirming that several months' reviews were not available after contacting the previous pharmacy. A third resident with hypertension, anxiety disorder, and manic depression also lacked a pharmacy review for July, with the DON unable to locate the required documentation. Facility policy required psychoactive medications to be reviewed in accordance with regulatory requirements, but the required monthly pharmacist reviews were not consistently completed or documented for these residents.
Failure to Ensure Resident Meals Delivered at Safe and Appetizing Temperatures
Penalty
Summary
A deficiency occurred when a resident's meals were repeatedly delivered to her room while she was asleep, resulting in the food sitting unattended and cooling to unappetizing and unsafe temperatures. The resident reported that her meals were served cold and that staff did not always wake her up upon delivery. Observations confirmed that on multiple occasions, the resident was asleep with her meal tray left on her bedside table, and she was unaware that her food had been delivered. When asked, the resident expressed a preference to be awakened for meal delivery, contradicting staff statements that she did not want to be disturbed. Food temperature checks revealed that the meals were below required temperatures, with the eggs measured at 83 degrees Fahrenheit, well under the standard of over 140 degrees Fahrenheit for hot foods. The resident's care plans did not include her preferences regarding meal delivery, despite her need for set-up assistance and her stated wishes. Interviews with staff indicated a lack of clarity about the resident's preferences, and the facility lacked a specific policy for room tray delivery. Additionally, other residents reported receiving cold food in their rooms and felt they should not have to request reheating. Facility documents outlined expectations for timely and safe meal delivery and maintaining proper food temperatures, but these were not followed in practice for this resident.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, as evidenced by two separate incidents involving two residents. In the first incident, a resident reported that a CNA was rough and grouchy while assisting her, which hurt her feelings. The CNA was later suspended pending an investigation. The resident had a history of major depressive disorder, anxiety disorder, and other health issues, and was unable to be interviewed at the time of the survey. In the second incident, another resident reported a care concern with a different CNA, who allegedly yelled at her and her roommate, and scolded her for wanting to wear two briefs. The resident, who had a history of psychotic disorder with hallucinations, major depressive disorder, and dementia, expressed that she felt mistreated and did not want the CNA to care for her again. This resident was also unable to be interviewed at the time of the survey.
Failure to Follow Hoyer Lift Transfer Protocol
Penalty
Summary
The facility failed to ensure that two staff members were present during a Hoyer lift transfer, leading to an accident involving a resident. The incident involved a CNA who attempted to transfer a resident using a Hoyer lift without the assistance of a second staff member, as required by the facility's policy. During the transfer, the resident moved her hands, causing her to slide out of the lift onto a recliner, and then onto the floor due to poor positioning. The resident, who had a history of major depressive disorder, pain, anxiety disorder, frontotemporal neurocognitive disorder, moderate protein-calorie malnutrition, and difficulty walking, complained of pain following the incident and was administered pain medication. The root cause of the fall was identified as the CNA's decision to perform the transfer alone, despite being aware of the policy requiring two staff members for such procedures. The CNA admitted to knowing the requirement but chose not to wait for assistance. This incident was documented in the resident's clinical record and was further corroborated by an IDT progress note. The facility's policy on mechanical lift transfers, which mandates the presence of a second staff member, was not adhered to, resulting in the resident's fall and subsequent pain.
Failure in Narcotic Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure proper administration and documentation of narcotic medications for two residents, leading to a deficiency in pharmaceutical services. On 10/11/24, several residents reported not receiving their medications from RN 10, an agency nurse. The Electronic Medication Administration Record (EMAR) for Resident C showed no documentation of receiving prescribed doses of Cyclobenzaprine and Norco, despite the narcotic count sheet indicating administration by RN 10. Similarly, Resident D's EMAR lacked documentation for Oxycodone administration, although the narcotic sheet showed it was signed out by RN 10. Resident D reported receiving only Tylenol and not the prescribed Oxycodone, corroborated by a handwritten document noting RN 10's strange behavior. Resident H also experienced a lack of documentation for Oxycodone administration on the same date, with the narcotic sheet indicating it was signed out by RN 10. The facility's policy required documentation of all administered medications in the EMAR and on the narcotic sheet, which was not followed in these cases. The failure to adhere to the medication administration policy resulted in a deficiency, as the residents did not receive their prescribed narcotic medications, and the documentation was not accurately maintained.
Failure to Protect Resident from Sexual Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a contracted housekeeping staff member. The incident occurred when a housekeeper was found on top of a resident in the dementia unit, with his pants down and the resident's gown and brief pulled up and open, respectively. This was witnessed by the Housekeeping Supervisor, who immediately intervened and called the police. The resident involved, identified as having severe cognitive impairment due to Alzheimer's disease and other conditions, was unable to understand or communicate effectively, which contributed to her vulnerability. The resident's care plan indicated she required maximum assistance with personal care and had a self-care performance deficit due to her dementia. She was also noted to have a functional limitation in her range of motion to both lower extremities. The resident's primary language was not English, and she was rarely understood even with translation assistance. At the time of the incident, the resident was found lying in bed, staring blankly at the ceiling, and did not appear to be in distress. The facility's policy on abuse, neglect, and exploitation, dated January 2024, emphasized the right of each resident to be free from abuse. However, the incident revealed a failure in the facility's protective measures, as the housekeeper was able to access and assault the resident. The housekeeper had a history of verbal warnings for tardiness and unsatisfactory job performance, which were documented in his employee file. The deficiency was identified as an immediate jeopardy situation, indicating a serious breach in resident safety and care standards.
Resident Abuse by Staff Member
Penalty
Summary
The facility failed to ensure a resident with dementia was free from physical abuse. A staff member, identified as CNA 1, was observed by another staff member, CNA 2, pulling a resident by the ears to remove him from another resident's room. This incident resulted in redness on the resident's ears. The resident, who was residing in the memory care unit, had a medical history that included dementia, chronic obstructive pulmonary disease, anemia, and peripheral vascular disease. The incident was reported to the Director of Nursing (DON) by CNA 2, who witnessed the abuse and intervened to protect the resident. The clinical records and nursing progress notes indicated that the resident's left ear was slightly red following the incident, and the redness was observed by a nurse practitioner the following day. CNA 1 claimed that the redness was due to shaving the resident earlier in the day, but CNA 2 reported that CNA 1 twisted the resident's ear while reprimanding him for entering another resident's room. The facility's policy on abuse, neglect, and exploitation emphasizes the residents' right to be free from abuse, and the incident was documented as a violation of this policy.
Misappropriation of Residents' Property and Financial Assets
Penalty
Summary
The facility failed to protect the personal property of two residents, leading to incidents of misappropriation. In the first case, a resident's daughter discovered that her father's AirPods were missing during a visit. The AirPods were later pinged to the address of a CNA employed at the facility. Despite the CNA's denial of involvement, the facility terminated her employment due to the evidence linking the AirPods to her address. This incident highlights a lapse in the facility's ability to secure residents' belongings and prevent unauthorized access by staff. In the second case, a resident's son noticed an unauthorized charge on his mother's credit card statement for a restaurant purchase. The resident was unable to leave the facility independently, suggesting that someone else used her card without permission. The facility's investigation revealed that the transaction was made in person at a nearby restaurant. Despite the resident's refusal to lock up her valuables, the facility failed to ensure the security of her financial assets, resulting in the misuse of her credit card.
Privacy Breach in Medication List Handling
Penalty
Summary
The facility failed to ensure the privacy of a resident's medication list during an admission process, affecting one of the five residents reviewed for resident-identifiable information. The incident involved Resident C, whose medication information was incorrectly sent to the hospital. This error led to a significant delay in administering the correct medications to the resident. The mistake was identified when the resident's niece discovered that the medication list in the envelope was for another resident, Resident N, instead of Resident C. The niece reported the discrepancy to the hospital staff, who then contacted the facility to obtain the correct medication list. The error occurred when two LPNs, LPN 8 and LPN 9, were preparing Resident C for a transfer to an appointment. LPN 8 printed the resident's face sheet, while LPN 9 printed the medication list for another resident, Resident N. Without verifying the name on the medication sheet, LPN 8 placed it in the envelope with the face sheet, which was then sent to the hospital. This breach of privacy was a violation of HIPAA regulations, as it involved the inappropriate disclosure of protected health information (PHI).
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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