Kingston Health Center Of Fort Wayne
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Wayne, Indiana.
- Location
- 1010 W Washington Center Rd, Fort Wayne, Indiana 46825
- CMS Provider Number
- 155479
- Inspections on file
- 39
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Kingston Health Center Of Fort Wayne during CMS and state inspections, most recent first.
A QMA worked with an expired license and administered medications to ten residents on two occasions. The Administrator and DON confirmed the lapse and were unable to provide a policy on license verification during the survey.
Surveyors observed that the facility did not consistently maintain required sanitization levels for cleaning solutions in the kitchen, as dipstick tests repeatedly failed to show the minimum 150ppm concentration when using chemical release towels. Only after using a wall-mounted sanitizer dispenser did the solution meet standards. No policies were provided for the use of towels as a substitute for the dispenser, and most residents consumed food prepared in the affected kitchen.
A resident with dementia and a history of wandering exited the facility through a service hall door that was not properly secured or alarmed, despite care plan interventions and physician orders for a wanderguard. Staff were unaware of a delay in the door's rearming mechanism, and the incident was not immediately documented or assessed. Not all staff had received in-service training on elopement policies or the secured door system.
The facility did not provide or document required bed hold policy notifications prior to the discharge or transfer of three residents with complex medical needs. Discharge packets were incomplete or missing, and there was no evidence in the records or progress notes that the bed hold policy was explained or given to residents or their representatives, contrary to facility policy.
A resident with dementia and hemiplegia, requiring substantial ADL assistance, was repeatedly observed with long facial hair and dark debris under her fingernails during meals. Staff confirmed that nail and facial hair care should have been provided and that the resident had not refused such care. Review of records and care plans showed no documentation of care refusal, and facility policies requiring regular grooming and documentation were not followed.
A resident with multiple diagnoses did not receive oxygen therapy as ordered by the physician, with observations showing the oxygen concentrator was either off or set above the prescribed rate. Staff interviews confirmed the discrepancy, and the DON acknowledged that changes to oxygen administration require a new physician order.
The facility did not maintain adequate communication and documentation with the dialysis center for two residents with end stage renal disease, resulting in missing vital information such as vital signs, weights, dialysis run times, post-dialysis assessments, and medication details. There was no evidence that the facility attempted to obtain the missing information, despite policy requirements and the importance of this information for resident care.
A resident with right-sided paralysis and expressive aphasia reported being rushed and handled roughly by a CNA during personal care. Despite the resident's daughter raising concerns to staff, there was no follow-up documentation or evidence of a thorough investigation, and grievance forms were not readily available as required by facility policy.
A resident with a history of dementia and a recent hip surgery was not properly assessed or monitored for a surgical wound upon readmission to the facility. The facility's records lacked documentation of wound care or monitoring for infection, despite the presence of a surgical wound. Interviews with staff indicated that the wound should have been assessed and documented, but the facility did not have a specific policy for surgical wound care.
A facility failed to maintain accurate medical records for a resident with bipolar disorder, leading to discrepancies in medication management and dietary needs. The resident's elevated lithium levels were not properly documented or communicated, resulting in inconsistent medication adjustments. Additionally, the resident's edentulous status was not recorded, affecting his diet. Interviews revealed a lack of documentation policy, contributing to the deficiency.
The facility failed to provide a dignified dining experience as some residents were not served meals simultaneously, leading to delays and dissatisfaction. A resident, without training or supervision, disrupted others by clearing tables during the meal. The facility's policy did not specify serving meals table by table, contributing to the issue.
The facility failed to prepare pureed food according to guidelines for five residents with specific dietary needs. A dietary staff member used unmeasured gravy and breaded pork tenderloin patties instead of following a recipe, resulting in inconsistent puree consistency. The residents had various medical conditions, including dysphagia, and required specific dietary textures. The facility's policy required the use of recipes, but this was not adhered to, leading to the deficiency.
The facility failed to ensure a sanitary environment in the dining room, where a resident was observed bussing tables without gloves or hand hygiene, spreading food residue. Other residents confirmed this was common due to short staffing, with no training provided. The DON acknowledged the lack of education on hand hygiene for the resident involved, despite the facility's infection control policy emphasizing a safe and sanitary environment.
A facility failed to ensure the timely formulation of an advanced directive for a cognitively intact resident after hospital readmission. The resident's DNR order was discontinued and not reinstated for several days, despite the care plan indicating a DNR status. Interviews revealed a lapse in updating the resident's code status, leading to an assumption of full code status until corrected.
The facility failed to complete all MDS sections for two residents, resulting in a deficiency. One resident's quarterly MDS lacked a BIMS score, with the therapy department responsible for section C completion. The MDS Coordinator was aware of the issue, which persisted for months. Another resident's admission MDS also missed a BIMS score, despite the resident's ability to converse and recall information. Meetings to address assessment timing were held, but no specific interventions were listed. The facility's policy lacked guidelines for MDS section completion.
A facility failed to provide trauma-informed care for a resident with PTSD, as the Trauma Screening Questionnaire was not completed upon admission, and no care plan was in place to address PTSD-related triggers. The resident's insomnia was not linked to PTSD, and there was no evidence of family collaboration or counseling attempts. The MDS was incomplete, and staff interviews revealed a lack of understanding and communication regarding the resident's PTSD triggers.
A resident experienced unrelieved pain due to delayed administration of pain medications and prolonged periods of sitting. The facility failed to develop and implement a comprehensive pain management plan, leading to the resident's early discharge due to ineffective pain control.
Unlicensed QMA Administered Medications
Penalty
Summary
The facility failed to ensure that a Qualified Medical Assistant (QMA) maintained a current license, as required for licensed staff. Record review showed that the QMA's license had expired, and interviews with the Administrator and Director of Nursing (DON) confirmed that the QMA worked on at least two occasions while her license was expired, administering medications to ten residents. The Administrator was initially unaware if the QMA had worked during the lapse, and the DON later provided timesheets confirming the QMA's work during the period of expired licensure. No policy regarding license verification was provided by the time of the survey exit.
Failure to Maintain Safe Sanitization Parameters for Kitchen Cleaning Solutions
Penalty
Summary
The facility failed to ensure that sanitization parameters for cleaning solutions used in the kitchen met professional standards. During multiple observations, the Dietary Manager (DM) tested the sanitization solution in the main kitchen using dipsticks, but the test strips did not change color, indicating the solution did not meet the minimum required concentration of 150ppm. The DM explained that chemical release towels were used to introduce the sanitizing chemical into the water, but even after changing the water and towels, the solution still did not reach the required strength during subsequent testing. Only after repeated attempts did the solution in the main kitchen reach the minimum standard, while the secondary kitchen's sanitization bucket continued to fail the test until it was refilled from a wall-mounted dispenser, at which point it tested at 300ppm. The report notes that 106 of 109 residents consume food prepared in the facility kitchen, but there were no policies provided regarding the use of towels as a replacement for the wall-mounted sanitization units. The observations and interviews confirm that the facility did not consistently maintain safe sanitization parameters for cleaning solutions in areas where food is prepared and served.
Failure to Secure Exit Door Results in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, cognitive impairment, and a history of wandering exited the facility through a side service hall exit door that was not properly secured. The resident was independently ambulatory, had demonstrated exit-seeking behaviors, and was assessed as being at significant risk for elopement. The care plan included the use of a wanderguard and regular checks of its function, and physician orders specified placement of the wanderguard and monitoring each shift. Despite these interventions, the resident was able to leave the building undetected and was only noticed by a dietary employee outside, after which the resident was promptly escorted back inside. Investigation revealed that the service hall exit door was not armed with wanderguard locking devices but was equipped with an alarm system that should have sounded when the door was opened. However, staff did not hear the alarm at the time of the incident. Subsequent testing by facility staff showed that the alarm did not sound when the door was opened, and it was unclear why the alarm had been disarmed. There was also confusion among staff regarding the door's locking mechanism, specifically about a delay in the door rearming after being closed, which was not widely understood by staff members. Documentation and interviews indicated that the event was not immediately or thoroughly documented in the resident's progress notes, with no immediate intervention or physical assessment recorded following the elopement. Staff in-service records showed that not all employees had received training on the elopement policy or the secured door system at the time of the incident. Manufacturer guidelines for the door's alarm system were reviewed, highlighting the potential for a rearm delay, but staff were generally unaware of this feature. The facility's policy required immediate assistance and documentation when a resident elopes, which was not fully followed in this case.
Failure to Provide Bed Hold Policy Documentation Prior to Resident Discharge
Penalty
Summary
The facility failed to provide required bed hold policy documentation and notification prior to the discharge or transfer of three residents. For each resident reviewed, there was no evidence in the medical record or discharge packet that the bed hold policy was explained or provided to the resident or their representative before transfer to the hospital. Specifically, discharge packets were either missing, incomplete, or left unsigned and undated, and progress notes did not mention any discussion or provision of the bed hold policy. In one case, the facility was unable to provide any documentation for a discharge event, and in another, the administrator confirmed that no bed hold policy was available for the date in question. The residents involved had significant medical conditions, including stroke, heart failure, seizures, diabetes, respiratory disease, and dementia. Despite the facility's policy stating that the bed hold notice and policy should be issued at the time of transfer or within 24 hours, there was no documentation to show that this requirement was met for any of the three residents. Interviews with the administrator revealed a lack of awareness regarding the need for documented proof of bed hold policy notification prior to discharge.
Failure to Provide Adequate Nail and Facial Hair Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. Observations revealed that the resident had long, white facial hair on her chin and upper lip, as well as dark brown debris under several fingernails on both hands during multiple meal times. The debris under the nails did not match any food items served, and the resident's facial hair was noticeably long. Staff interviews confirmed that the resident's hands and nails should have been cleaned prior to meals and that facial hair should have been groomed, especially since the resident had not refused such care in the past. Record review indicated the resident had diagnoses of dementia with cognitive impairment and hemiplegia following a stroke, requiring substantial assistance with personal hygiene. The care plan specified the need for ADL assistance, including dressing and grooming, and required documentation of care provided. There was no documentation of care refusal in the progress notes. Facility policies required regular nail cleaning and facial shaving, with documentation of any refusals, but these were not followed for this resident.
Failure to Follow Physician's Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow physician's orders for oxygen administration for a resident with diagnoses including Parkinson's disease, restlessness and agitation, and squamous cell carcinoma. Multiple observations over several days showed that the resident's oxygen concentrator was turned off and the nasal cannula was not in use, despite a physician's order to titrate oxygen via nasal cannula between room air and 2LPM to maintain oxygen saturation at or above 90% every shift. On subsequent days, the resident was observed receiving oxygen at 5LPM, which exceeded the physician's order. Staff interviews confirmed that the oxygen was set at 5LPM and that the resident's oxygen saturation was 95%. Upon realizing the discrepancy, staff adjusted the oxygen flow to 2LPM as per the order. The Director of Nursing confirmed that any change in oxygen administration outside of the physician's order would require a new order. Review of facility policy indicated that physician orders and progress notes should be maintained according to regulations, but the policy did not specifically state that physician orders must be followed. The deficiency was identified due to the failure to administer oxygen as prescribed and to ensure staff adhered to the physician's orders for respiratory care.
Failure to Ensure Ongoing Communication and Documentation for Dialysis Care
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis center for two residents diagnosed with end stage renal disease, diabetes, and either hypertension or hypotension, who had physician orders for dialysis three times per week. For both residents, multiple entries in the dialysis communication book were missing critical information from the dialysis center, including vital signs, weights, run times, dry weights, post-dialysis assessments, information on complications, medications administered, and whether labs were drawn. In some instances, the forms referenced attachments for medication details, but no such attachments or dosage information were present. There was no documentation in either resident's medical record indicating that the facility made further attempts to obtain the missing information from the dialysis center. During an interview, the Assistant Director of Nursing acknowledged the importance of this communication for monitoring complications and ensuring proper follow-up care, and stated that the expectation was to call the dialysis center to obtain the necessary information and document it accordingly. The facility's policy required collaboration with the dialysis provider and monitoring of residents before, during, and after dialysis treatments, but this was not followed as evidenced by the missing documentation and lack of follow-up.
Failure to Investigate and Document Resident Grievance
Penalty
Summary
The facility failed to ensure that grievances were thoroughly investigated, properly documented, and that appropriate corrective actions were taken for a resident who reported being rushed and handled roughly during personal care by a CNA. The resident, who had hemiplegia and hemiparesis following a stroke, was alert, oriented, and able to communicate her needs, despite expressive aphasia. After the incident, the resident's daughter reported concerns to nursing staff, and although the nurse checked on the resident and found no visible injuries, there was no further follow-up documentation in the medical record from the time of the complaint through the resident's discharge. Interviews with facility staff revealed a lack of clarity and consistency in the grievance process. The Social Services Director was unaware of how grievances were being tracked or resolved and reported no grievances for the relevant months. The Administrator stated that grievance forms were available, but during the survey, no forms were found in common areas or at the Social Services Director's office. The DON acknowledged that there was no documentation to show that the grievance had been addressed or that actions were taken to prevent further violations. The facility's policy required grievances to be tracked, investigated, and followed up within a specified timeframe, but these procedures were not followed in this case.
Failure to Monitor Surgical Wound
Penalty
Summary
The facility failed to properly assess and monitor a surgical wound for Resident P, who had a history of dementia with behavioral disturbance and a fracture of the right femur. After a fall on 12/17/24, Resident P underwent a right hip cemented hemiarthroplasty on 12/19/25. Upon readmission to the facility on 12/23/24, the Admission Evaluation and Baseline Plan of Care did not document the presence of a surgical wound, its condition, or any signs of infection. This lack of documentation persisted despite the resident having a surgical wound as indicated in the admission Minimum Data Set assessment dated 12/28/24. The facility's records, including the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for December 2024, did not show any surgical wound care, assessment, or monitoring for signs of infection. A nurse note on 12/24/24 mentioned moderate bleeding from the surgical site, but there was no documentation of physician notification or further wound assessment. From 12/25/24 to 1/6/25, there was no documentation regarding the surgical wound's status, including the condition of the staples or any signs of infection. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed that the surgical wound should have been assessed and documented upon admission and monitored every shift. However, the facility lacked a specific policy for surgical wound care, relying instead on a general Wound and Skin Management Protocol. This protocol required an admission assessment within 24 hours and a plan of care for skin integrity, which was not adequately followed for Resident P's surgical wound.
Deficiency in Medical Record Accuracy and Resident Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for Resident D, as evidenced by several discrepancies in medication management and documentation. Resident D, who had a history of bipolar disorder, was prescribed Lithium Carbonate 300 mg ER twice daily. Despite an elevated blood lithium level of 1.6 mmol/L, there was no documentation of a physician order for the lab test or notes indicating the abnormal results were communicated to the doctor or NP. The medical NP adjusted the lithium dosage due to increased tremors, but the resident's wife expressed concerns about the change, leading to a reversion to the original dosage. However, the psychiatric NP later decreased the dosage again without nursing documentation explaining the change. Additionally, the facility failed to document Resident D's edentulous status, which affected his dietary needs. The initial nursing admission form did not note any oral issues, and the resident was placed on a regular texture diet despite having no teeth. A speech therapy evaluation later identified the resident's difficulty with chewing and swallowing, recommending a swallow study. However, there were no physician orders for this evaluation or study, and the resident's care plans did not reflect his need for soft foods. Interviews with the DON revealed a lack of policy regarding documentation, and no policy was available for review at the time of the survey exit. This lack of documentation and communication regarding Resident D's medication and dietary needs contributed to the facility's failure to safeguard resident-identifiable information and maintain medical records in accordance with professional standards.
Deficient Dining Experience and Resident Involvement in Bussing Tables
Penalty
Summary
The facility failed to ensure a dignified dining experience for several residents, as observed during a dining session. Residents were not served their meals simultaneously, leading to delays and dissatisfaction. Specifically, Resident 49, Resident 76, and Resident 82 were seated together, but only Resident 49 received her meal initially, causing her to wait until her tablemates were served, resulting in her food becoming cold. The serving staff, identified as [NAME] 8, prioritized serving other tables before taking orders from Residents 76 and 82, which contradicted the facility's policy as explained by the Director of Nursing, who stated that residents at a table should be served at the same time. Additionally, Resident 77, who was not trained or supervised, took it upon herself to clear tables, disrupting other residents' dining experiences. She moved around the dining room, collecting dishes and silverware, and even moved Resident 49's wheelchair without consent. This behavior was not addressed by staff, and it was noted that residents often helped with bussing tables due to short staffing. The facility's policy on meal service did not specify that meals should be served table by table, contributing to the disorganized dining experience.
Failure to Prepare Pureed Food According to Guidelines
Penalty
Summary
The facility failed to ensure that pureed food was prepared according to guideline specifications for five residents requiring pureed diets. During an observation, a dietary staff member identified a pan of meat with charred spots and sticking to wax paper as pork tenderloin. The staff member used a grinder to puree the meat, adding unmeasured amounts of gravy instead of following a specific recipe. The recipe book did not include a recipe for pork tenderloin puree, and the kitchen manager was unaware of this omission. The dietary staff member used breaded pork tenderloin patties, which were not similar in style to the pork tenderloin served to other residents, and did not use a thickener, resulting in an inconsistent puree consistency. The residents involved had various medical conditions, including respiratory disease, heart disease, dementia, dysphagia, stroke, diabetes, Alzheimer's, adult failure to thrive, and malnutrition. Each resident had specific dietary orders for pureed or blenderized textures with thin or nectar thick consistencies. The facility's policy, dated April 2014, required the use of recipes when preparing menu items, but this policy was not followed, leading to the deficiency in food preparation for these residents.
Inadequate Infection Control in Dining Room
Penalty
Summary
The facility failed to maintain a sanitary environment in the dining area, specifically in the crown dining room, where 20 out of 108 residents consumed meals. During an observation, a resident was seen collecting plates, glasses, and silverware without wearing gloves or practicing hand hygiene. This resident had remnants of mashed potatoes on her hands and was touching tables and another resident's wheelchair, indicating a lack of sanitation. Staff in the dining room acknowledged the resident's actions but were unable to prevent them due to being occupied with other duties and being the only staff member present. Interviews with other residents revealed that it was common for residents to assist with bussing tables, especially during times of short staffing, without receiving any training or oversight on hand hygiene. The Director of Nursing confirmed that there was no available education on hand hygiene or sanitation principles for the resident involved in bussing activities. The facility's infection control policy, dated August 2019, emphasized maintaining a safe and sanitary environment, but there was no evidence of training or review of the resident's appropriateness for such tasks.
Failure to Ensure Timely Formulation of Advanced Directive
Penalty
Summary
The facility failed to ensure the formulation of an advanced directive for a resident after their readmission from the hospital. The resident, who was cognitively intact with a BIMS score of 14, had a history of respiratory failure, Parkinson's disease, and type 2 diabetes with chronic kidney disease. Upon review, it was found that the resident's DNR order was discontinued on 8/14/24 and not reinstated until 8/21/24, despite the resident's care plan indicating a DNR status. The resident declined to decide on an advanced directive status upon readmission on 8/19/24. Interviews with the facility's Administrator and DON revealed that the resident's code status should be documented in the physician orders and care plan. However, there was a lapse in updating the resident's code status, leading to an assumption of full code status until the DNR was reinstated on 8/21/24. The facility's policy required determining whether a resident had executed advanced directives and if a DNR order was desired while in the facility, which was not adhered to in this case.
Incomplete MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the completion of all Minimum Data Set (MDS) sections for two residents, leading to a deficiency. Resident 76's quarterly MDS assessment did not include a completed Basic Interview for Mental Status (BIMS) score, as each question was marked as not assessed. The Director of Therapy acknowledged that the therapy department was responsible for completing MDS section C and identified a problem with completion, which had been an issue for several months. The MDS Coordinator confirmed awareness of the incomplete or untimely completion of section C, indicating that the MDS department should receive completed sections by the end of the business day on the Assessment Reference Date. Resident 66's admission MDS also lacked a BIMS score assessment. During an interview, Resident 66 demonstrated the ability to converse, recall information, and use reasoning skills. Despite meetings held by the facility to address comprehensive assessment and timing, the Performance Improvement Plan (PIP) did not list any specific interventions. The facility's current policy did not provide guidelines for the completion of each MDS section, and an undated document indicated that the therapy department was responsible for BIMS scoring. The policy from April 2014 stated that MDS Nurses should complete every MDS within seven days of the assessment date.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with heart disease, depression, and PTSD. Upon review, it was found that the resident's Trauma Screening Questionnaire was not completed upon admission, and there was no care plan in place to address or mitigate PTSD-related triggers. The resident's insomnia was not identified as a symptom of PTSD, and there were no progress notes indicating family collaboration to identify PTSD triggers. Additionally, there was no evidence of counseling or talk therapy being attempted for the resident. The resident's admission Minimum Data Set (MDS) was incomplete, with sections for mental status and mood not fully assessed. Interviews with staff revealed a lack of understanding and communication regarding the resident's PTSD triggers. The Social Services Director admitted to not completing the mood section and expressed concern about upsetting the resident by discussing PTSD further. The Director of Nursing acknowledged that the resident should have been care planned for PTSD and monitored for triggers, but was unsure if the family had been contacted for additional information. The facility's policy on trauma-informed care was not followed, as the necessary screenings and interventions were not implemented.
Failure to Ensure Appropriate Pain Management
Penalty
Summary
The facility failed to ensure appropriate pain management for Resident Q, who was admitted for rehabilitation services following a pelvic fracture. Despite being prescribed Hydrocodone-Acetaminophen for pain, the resident reported experiencing unrelieved pain due to delayed administration of pain medications and prolonged periods of sitting in a chair and on the toilet. The resident's pain was not adequately assessed or managed, leading to her early discharge from the facility due to ineffective pain control. The resident's medical record indicated that pain medications were not administered timely, and non-pharmacological interventions were not consistently offered. The Medication Administration Record (MAR) showed significant gaps in the administration of pain medication, with the resident often waiting several hours between doses. Additionally, there was no documentation of non-pharmacological interventions being provided, despite the resident's complaints of severe pain. The facility's Director of Nursing confirmed that a comprehensive pain management plan, including non-pharmacological interventions, should have been developed and implemented for residents experiencing pain. However, the facility did not use a comprehensive pain assessment form, and there were no changes made to the resident's plan of care to address her pain management needs. The facility's policy on pain assessment and management was not followed, resulting in inadequate pain control for the resident.
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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