Paoli Health And Living Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Paoli, Indiana.
- Location
- 559 W Longest St, Paoli, Indiana 47454
- CMS Provider Number
- 155333
- Inspections on file
- 26
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Paoli Health And Living Community during CMS and state inspections, most recent first.
The facility failed to maintain a safe, sanitary, and homelike environment on multiple halls, as shown by a resident grievance about dirty laundry left in a room, persistent urine odors, and repeated observations of soiled towels and washcloths on room floors. Surveyors also found uncovered and unlabeled toothbrushes stored on sinks and a commode in shared restrooms, as well as uncovered bedpans stored between a handrail and the bathroom wall. An LPN acknowledged that bedpans and toothbrushes should be covered and properly stored in shared restrooms, and a QMA stated that staff should not leave linens on the floor after care, contrary to the facility’s infection control policy for handling linens and patient care equipment.
A resident with heart disease, heart failure, obesity, and atrial fibrillation was admitted from a hospital with an order for metoprolol tartrate 25 mg, 0.5 tablet BID, but the order was incorrectly transcribed into the facility MAR as 25 mg, 1 tablet BID. The resident consequently received four double-dose administrations of metoprolol before becoming short of breath during therapy, with documented hypotension and bradycardia that led to EMS transport and hospital observation. An RN later confirmed the transcription error, and staff described an admission checklist for verifying transfer orders and medications that was available but not required or incorporated into the resident record, despite a facility policy requiring accurate and careful transcription of physician orders.
Surveyors found that staff failed to follow infection control practices during multiple episodes of resident care, including incontinence care and assistance with toileting. CNAs performed dirty tasks such as removing soiled briefs and draw sheets, then moved on to clean tasks like applying new briefs, handling bedside drawers, and repositioning residents without changing gloves appropriately or performing hand hygiene between glove changes. In another case, a resident with an order for enhanced barrier precautions due to MRSA colonization was assisted to and from the restroom by a CNA and an LPN without the use of required gowns or other EBP measures, and the room lacked signage to alert staff that EBP was required, despite PPE supplies being present.
Surveyors found that MDS assessments were not accurately completed for several residents, including failures to document the use of anticoagulant, antiplatelet, and anticonvulsant medications, as well as omissions of cancer diagnoses and recent falls. These inaccuracies were confirmed by staff interviews and review of clinical records and medication administration records.
The facility did not maintain complete and accurate medical records for two residents who self-administered medications, as there were no documented assessments of their ability to do so safely, and for two other residents, documentation of dental and podiatry services was missing from their records. Staff interviews confirmed that required documentation, including service consents and family notifications, was not present in the clinical records.
Staff failed to maintain resident dignity and personal hygiene, including leaving a resident with an uncovered head dressing, not cleaning blood from a dependent resident's neck, failing to provide promised oral care, and not assisting another resident with grooming and cleanliness. These actions did not meet the facility's standards for respect and dignity.
Three residents requiring assistance with ADLs did not consistently receive support for bathing, nail care, and oral hygiene. One resident missed scheduled baths and wore the same clothing for an extended period, another was repeatedly observed with poor personal hygiene and missed showers, and a third had unaddressed nail and oral care needs. Staff interviews and documentation revealed missed care and lack of proper documentation, with no specific ADL policy in place.
A resident with diabetes and depression developed an open boil on the buttock, but after the initial assessment, staff failed to complete and document ongoing measurements and descriptions of the area as required by the care plan and facility policy. The ADON indicated that only certain wounds were routinely measured, and the boil was only visually observed without documentation, resulting in a lack of ongoing assessment for the open skin area.
A resident with a history of TBI, PTSD, and schizophrenia exhibited behaviors such as yelling at staff and refusing care, but staff failed to document these behaviors or update the care plan accordingly. Despite care plans requiring monitoring of behavior and mood due to psychotropic medication use, the facility did not follow its own behavioral health management policy to identify, monitor, and document behavioral events.
Staff did not follow infection control protocols during incontinence and feeding tube care for two residents, including failing to sanitize hands between glove changes, touching clean linens and residents with soiled gloves, and not properly cleaning soiled surfaces or addressing active bleeding. Hand hygiene lapses were observed before, during, and after care, and contaminated items were placed on clean surfaces.
The facility did not ensure all staff received adequate behavioral and mental health training as determined by its own assessment, resulting in insufficient education on individualized care, behavior monitoring, and interventions for residents with conditions such as schizophrenia, PTSD, and TBI. Staff were unaware of some residents' behavioral health diagnoses and appropriate interventions, and resident records lacked proper documentation of behavior monitoring.
A resident in an LTC facility alleged sexual abuse by a CNA, who admitted to inappropriate contact during care. The resident, with a history of cerebrovascular disease and other conditions, required significant assistance. The incident led to the CNA's arrest for sexual battery, highlighting a failure in the facility's abuse prevention policy.
A resident with hemiplegia and hemiparesis fell from a mechanical lift during a transfer, resulting in multiple fractures and a head laceration, leading to her death. The CNAs involved used an incorrect method for placing the lift pad, contrary to the operator's instructions, due to the resident's rigidity. The facility had not conducted specific assessments or provided adequate training for the use of the mechanical lift.
A facility failed to accurately report an allegation of sexual abuse involving a resident and a CNA to the state agency. The resident reported inappropriate contact by the CNA, which was not fully detailed in the facility's report. The CNA was suspended, terminated, and later arrested after admitting to the conduct during a police investigation.
A facility failed to follow a care plan requiring two staff members for a resident's transfer using a Hoyer lift. The resident, with multiple health issues, experienced pain when a CNA attempted the transfer alone, contrary to facility policy. Observations and interviews confirmed the need for two staff members during such transfers.
A resident's privacy was violated when facility staff shared two photographs of her on the facility's social media website without her consent. The resident had explicitly refused permission for her images to be used, as documented in a signed consent form. The images were later removed after the issue was brought to the staff's attention.
Failure to Maintain Sanitary and Homelike Environment in Resident Halls
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, sanitary, and homelike environment on three of four resident halls, as evidenced by persistent odors, improper storage of personal care items, and soiled linens left on floors. A grievance had been filed by a resident in December alleging that dirty laundry was left in the resident’s room. During the survey, a urine odor was noted on the 300 hall on two separate days. Multiple observations showed shared restrooms containing uncovered and unlabeled resident toothbrushes placed on the back of sinks and on the back of a commode, and uncovered bedpans stored between a handrail and the bathroom wall in shared restrooms. Additional observations on several occasions revealed towels and washcloths left on the floors of resident rooms, including near restroom doors, next to beds, and under the foot of beds. In interviews, an LPN stated that resident bedpans should be covered if stored in shared restrooms and that resident toothbrushes should be stored away and covered when in shared restrooms. A QMA stated that staff should not leave linens or washcloths on the floor after providing care and should clean up after themselves following care. Review of the facility’s infection control policy indicated that used linens and patient care equipment should be handled and transported in a manner that prevents exposure and avoids transfer of pathogens to other patients or the environment, which was not followed in these instances.
Medication Transcription Error Leading to Significant Metoprolol Overdose
Penalty
Summary
The deficiency involves a failure to ensure a resident was free from significant medication errors when a hospital discharge order for metoprolol tartrate was incorrectly transcribed into the facility’s medication administration record (MAR). The hospital discharge orders directed metoprolol tartrate 25 mg, 0.5 tablet twice a day, but the facility’s physician orders and MAR listed metoprolol tartrate 25 mg, 1 tablet twice a day. As a result of this transcription error, the resident received double the ordered dose of metoprolol for four administrations: the evening of 12/31/25, the morning and evening of 1/1/26, and the morning of 1/2/26. The resident’s diagnoses included heart disease, obesity, heart failure, and atrial fibrillation. During therapy on 1/2/26, the resident became short of breath, and vital signs showed hypotension with a blood pressure of 86/48 mm Hg and bradycardia with a pulse of 42 BPM. EMS was called, and the resident was transported to the hospital emergency department, where the hospital kept the resident for observation. In interviews, an RN confirmed that the metoprolol order from the hospital discharge paperwork had been entered incorrectly into the facility’s MAR, resulting in the resident receiving twice the ordered dose. Staff also reported that an admission checklist existed which included verification of physician orders and medications by two nurses, but this checklist was not required to be completed and was not part of the resident’s record. The facility’s transcribing orders policy stated that physician orders must be transcribed timely, completely, and accurately, and that great care must be taken to ensure accuracy and completeness when transcribing orders.
Failure to Follow Hand Hygiene, Glove Use, and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves failures in infection prevention and control practices during resident care, including improper glove use, lack of hand hygiene, and failure to implement ordered enhanced barrier precautions (EBP). During incontinence care for Resident C, two CNAs removed a wet brief and provided perineal care while wearing gloves, then one CNA applied a new brief, opened a bedside table drawer, retrieved and applied a tube of cream to the perineal area, and returned the tube to the drawer without changing gloves. The CNA then removed gloves, donned new gloves from a pants pocket without performing hand hygiene, and, along with the other CNA, repositioned the resident and adjusted the pillow before finally removing gloves and washing hands. In a separate observation involving Resident D, a CNA removed a soiled brief, provided perineal care, and removed a soiled draw sheet, then removed gloves and put on new gloves without performing hand hygiene. The CNA then held a clean sheet against his scrub top while rolling and placing it under the resident, applied a new brief, and, together with another CNA, adjusted the resident and pillow before removing gloves and performing hand hygiene. Another deficiency occurred with Resident F, who had a physician order for EBP after a positive methicillin-resistant Staphylococcus aureus (MRSA) nare swab at the hospital and documentation that the resident was colonized and to be placed in EBP. During observed assistance of Resident F from bed to the restroom and back, a CNA and an LPN did not wear gowns or implement EBP while providing this personal care. Although PPE supplies were present in the resident’s restroom, there was no signage indicating that EBP was required for the resident. An LPN later indicated that the resident had recently received an order for EBP and that a sign was still needed in the room to indicate to staff that PPE should be used for all personal care, as the physician’s order did not specify particular care tasks.
Inaccurate MDS Assessments for Medications, Diagnoses, and Incidents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for several residents, resulting in incomplete or incorrect documentation of medications, diagnoses, and incidents. For one resident with a history of stroke, hypertension, and congestive heart failure, the most recent MDS assessment did not reflect the use of antiplatelet and anticoagulant medications, despite current physician orders and medication administration records confirming daily administration of these drugs. Another resident with dementia and anxiety experienced multiple falls within the assessment period, but these incidents were not recorded on the corresponding MDS assessment. Additionally, a resident with diabetes, depression, and hypertension had an MDS assessment that failed to accurately document the administration of insulin injections and the use of an anticonvulsant, even though medication records showed consistent administration during the look-back period. In another case, a resident with a diagnosis of malignant melanoma did not have cancer documented on the most recent MDS assessment, despite the diagnosis being present in the clinical record and confirmed by the resident. Interviews with MDS staff confirmed that these omissions were errors and that the information should have been included in the assessments.
Failure to Maintain Complete and Accurate Medical Records for Medication Self-Administration and Ancillary Services
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, specifically in the areas of self-administration of medications and documentation of ancillary services. For two residents who self-administered medications, there was no documented assessment to confirm their ability to safely self-administer, nor was there evidence that staff observed or evaluated their competency in this area. In one case, a resident was permitted to self-inject insulin without any formal assessment or documentation, and staff indicated that no self-administration assessment was completed because they believed the standard questions did not apply. Another resident self-administered a nasal spray without a physician's order or care plan reflecting this preference, and there was no documentation of the resident's ability to use the medication correctly. Additionally, the facility did not accurately document ancillary services for two residents. Family members reported not being informed about dental visits, and clinical records lacked notes from dental and podiatry providers, even though these services were reportedly provided. In one instance, a resident's oral and nail hygiene was observed to be poor, but there was no documentation of recent dental or podiatry visits, nor was there a signed consent or refusal for ancillary services in the clinical record. Staff interviews confirmed that documentation of these services, including refusals and notifications to family, was missing from the residents' records. The facility was unable to provide policies or documentation supporting accurate and complete record-keeping for these areas. While a dental services policy was available, there was no specific policy for accurate documentation, and the nurse job description only generally referenced the need to complete required documentation. The lack of proper documentation and assessments led to incomplete medical records for the affected residents.
Failure to Maintain Resident Dignity and Personal Hygiene
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, as evidenced by multiple observations and interviews involving three residents. One resident with anemia, hypertension, and anxiety disorder was observed with an uncovered, undated yellow gauze dressing on her forehead. The LPN applied the dressing without securing or covering it, despite the resident's preference for it to be covered to avoid feeling stared at. The Assistant Director of Nursing confirmed that the resident sometimes had the gauze covered for dignity reasons, but this was not consistently done. Another resident with traumatic brain injury, schizophrenia, and dysphagia, who was totally dependent on staff, was observed during incontinence care where a CNA leaned over him and roughly removed a soiled sheet while the resident's back was still on it. The resident was left with blood running down his neck from a bleeding sore, which was not cleaned, and staff failed to notify a nurse. Later, the resident, who was NPO, repeatedly requested water, but the nurse did not provide oral care as promised, and a cup of water with a straw was left at the bedside despite the NPO status. The resident's mouth was observed to be in poor condition, with a strong odor and peeling skin inside the mouth. A third resident with Parkinson's disease, dementia, and schizophrenia was observed multiple times with dried food on his mouth and shirt, long fingernails with a brown substance underneath, and a thick white film on his teeth. His hair was also observed to be disheveled. The resident was dependent on staff for personal hygiene, oral care, and grooming, but these needs were not met, as confirmed by both staff and family members. The facility's policy requires residents to be treated with kindness, respect, and dignity, but these standards were not upheld in the care provided to these residents.
Failure to Provide Adequate ADL Assistance Including Bathing, Nail, and Oral Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), including bathing, nail care, and oral care, for three residents who required such support. One resident, who was cognitively intact and required substantial to maximal assistance, reported not receiving scheduled baths and was observed wearing the same dress for over a week. Documentation showed gaps in recorded complete baths, with no refusals documented, despite the resident's care plan specifying her bathing preferences. Another resident, dependent on staff for showering and requiring assistance with personal hygiene, was repeatedly observed with dried food on his mouth and shirt, long fingernails with a brown substance underneath, and a thick white film on his teeth. Family members expressed ongoing concerns about his cleanliness, and records indicated missed showers without documentation of refusals. The care plan conference had previously noted similar issues raised by the resident's wife. A third resident, totally dependent on staff, was observed with long toenails, dirty fingernails, and poor oral hygiene, including strong mouth odor and peeling skin inside the mouth. Although oral care was supposed to be provided, it was not completed as observed. The resident's clinical record showed multiple missed showers without documentation of refusals. Staff interviews confirmed the existence of a shower schedule and expectations for nail and oral care, but also revealed inconsistencies in documentation and follow-through. The facility did not have a specific ADL policy, relying instead on a general resident rights policy.
Failure to Assess and Document Open Skin Area
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care and services for a resident with an open skin area. The resident, who had diagnoses including diabetes mellitus and depression, was identified as having a boil on the buttock that was open and draining. Although initial documentation included a description and measurement of the area, subsequent assessments and measurements were not completed or documented after the initial event. The clinical record lacked ongoing assessments of the open area, and there was no documentation explaining the discontinuation of prescribed mupirocin ointment. Additionally, the care plan required recording the location, size, and characteristics of the boil, but this was not consistently done. Staff interviews revealed that the resident sometimes refused observation, but at times allowed the area to be checked. The ADON stated that only certain types of wounds were routinely measured and documented, and considered the boil to be similar to a skin tear, which was only visually observed without documentation. The facility's wound management policy required the wound team to assess all new or open wounds, but this was not followed for the resident's boil. As a result, there was a lack of ongoing assessment and documentation for the resident's open skin area.
Failure to Document and Monitor Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with multiple behavioral health diagnoses, including traumatic brain injury, post-traumatic stress disorder, and schizophrenia. Observations showed the resident exhibiting behaviors such as yelling at staff and refusing care, but the clinical record lacked documentation of these behaviors. The resident's care plans for antipsychotic and antidepressant medications included interventions to monitor behavior and mood, yet there was no evidence in the record that these behaviors were being tracked or monitored as required. Interviews with staff, including CNAs and the DON, confirmed that the resident sometimes called staff names, refused care, or isolated himself, but these behaviors were not reflected in the care plan or documented in the clinical record. The facility's own behavioral health management policy required identification, monitoring, and documentation of behavioral events, especially for residents on psychotropic medications, but these procedures were not followed for this resident.
Failure to Maintain Infection Control During Incontinence and G-Tube Care
Penalty
Summary
Staff failed to maintain proper infection control practices during incontinence and feeding tube care for two residents. During incontinence care for one resident, certified nurse aides did not sanitize their hands between glove changes, touched clean linens and the resident's bare skin with soiled gloves, and placed soiled linens on clean bedding. Wash cloths were laid on the side of the bathroom sink, potentially contaminating them, and were then used to wipe the resident. The resident was rolled onto a urine-soaked sheet, and the mattress was not properly cleaned or allowed to dry before clean linens were applied. Additionally, the resident's bleeding chin was not addressed, and blood was left on the resident's neck and bed sheet, which was not changed after care or following medication administration through a gastrostomy tube by a registered nurse. In a separate incident, a licensed practical nurse performed feeding tube care for another resident without proper hand hygiene. The nurse did not clean hands before or after entering the room, handled a soiled washcloth identified as having stool, removed gloves without washing hands, and then donned new gloves. The nurse continued with the feeding tube procedure, including checking tube placement, administering feeding and water flushes, and handling equipment, all without appropriate hand hygiene between tasks. The nurse only washed hands after removing gloves, gown, and mask at the end of the procedure. The infection preventionist confirmed that staff should sanitize hands and change gloves between dirty and clean tasks, avoid touching residents or clean linens with soiled gloves, and ensure soiled linens are not placed on clean bedding. The infection preventionist also stated that contaminated wash cloths should not be placed on the side of the sink, and that mattresses should be cleaned and dried if soiled. The facility's incontinence care skills validation form indicated that hand washing and glove use are required, but these practices were not consistently followed by staff during the observed incidents.
Failure to Provide Adequate Behavioral Health Training and Monitoring
Penalty
Summary
The facility failed to implement a sufficient and competent behavioral and mental health training program for all staff, as required by the facility assessment and resident needs. The facility assessment identified a population with a range of behavioral health needs, including psychosis, impaired cognition, mental disorders, depression, bipolar disorder, schizophrenia, PTSD, anxiety, TBI, Down Syndrome, autism, Alzheimer's disease, non-Alzheimer's dementia, and behaviors requiring intervention. Despite this, in-service training records from the past year lacked documentation of education on individualized care, behavior monitoring, non-pharmacological interventions, and specific approaches for residents diagnosed with schizophrenia, PTSD, and TBI. Staff interviews confirmed a lack of training on these specific diagnoses, with CNAs unaware of certain residents' behavioral health conditions, their triggers, or appropriate interventions. Additionally, the facility's behavioral health management policy required identification, monitoring, and management of behavioral events, as well as individualized services based on resident needs. However, the absence of adequate behavioral health in-services and training led to failures in behavior monitoring and documentation in resident clinical records. Staff were not consistently informed about residents' behavioral health diagnoses or how to address them, resulting in non-compliance with the facility's own policies and regulatory requirements.
Failure to Protect Resident from Sexual Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by staff, resulting in an incident involving a Certified Nurse Aide (CNA) and a female resident. The resident, who was alert and oriented, alleged that the CNA lifted her gown and engaged in inappropriate sexual contact by licking or sucking on her breast. This incident was reported to have occurred a week prior to the resident's allegation on December 28, 2024. The CNA admitted to the police that he engaged in the act, claiming it was done at the resident's request to silence her. The resident expressed distress during interviews, indicating she did not consent to the act. The resident involved had a medical history that included cerebrovascular disease, major depressive disorder, anxiety, dysphagia, altered mental status, and chronic pain. She required substantial assistance for mobility and toileting, as noted in her care plan. The facility's investigation revealed that the CNA was often alone with the resident and had been accused of inappropriate behavior. The incident was reported to local law enforcement, leading to the CNA's arrest for sexual battery. The facility's policy on abuse prevention was not adhered to, resulting in this deficiency.
Resident Falls from Mechanical Lift Due to Improper Use
Penalty
Summary
The facility failed to ensure a resident was free from accidents during a transfer using a mechanical lift. The incident involved a resident who was being transferred by two CNAs using a mechanical lift. The lift pad was incorrectly placed under the resident's legs instead of through them, contrary to the operator's instructions. This improper method was used due to the resident's rigidity in her lower extremities, and no assessment had been completed to determine if the resident was suitable for this method. As a result, the resident slid feet first out of the lift pad, leading to multiple fractures and a head laceration. The resident, who had a history of hemiplegia and hemiparesis, was dependent on mechanical lift transfers with two assistants. During the transfer, the resident fell approximately 3.5 to 4 feet from the lift, sustaining severe injuries including fractures to both femurs, the left tibia, and the right ankle, as well as a head laceration. The resident was transferred to a local emergency department, where she later expired. The CNAs involved in the transfer did not follow the mechanical lift's operator instructions, which required the lift pad to be placed through the resident's legs unless the resident had good torso stability, which this resident did not possess. The facility's investigation revealed that the CNAs had not been adequately trained or assessed for competency in using the mechanical lift with the under-leg method. The facility lacked specific assessments to determine the appropriate transfer method for residents requiring mechanical lifts. The CNAs involved in the incident were not aware of the correct procedure, and the facility had not provided adequate training or competency checks for the use of the mechanical lift prior to the incident.
Failure to Accurately Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to completely and accurately report an allegation of sexual abuse involving a resident to the state agency. The incident involved a resident who reported that a Certified Nurses Aide (CNA) made inappropriate contact with her chest area during care. The resident initially did not report the incident to staff but mentioned it to a supposed roommate, who did not exist. The facility's investigation did not find any witnesses to the alleged inappropriate actions, but the CNA was suspended and later terminated. A police report was filed, and the police department began an investigation, which led to the CNA's arrest after admitting to the inappropriate conduct. The facility's policy on abuse, neglect, and misappropriation requires immediate reporting of such allegations to the state licensing/certification agency and local law enforcement. However, the facility's report to the state agency was incomplete and inaccurate, as it did not fully detail the nature of the allegation. The police investigation revealed that the CNA admitted to the actions, which were initially reported to the police by the facility staff. The facility's failure to report the complete details of the allegation to the state agency constitutes a deficiency in their reporting obligations.
Failure to Implement Care Plan for Resident Transfer
Penalty
Summary
The facility failed to implement the care plan for a resident who required assistance from two staff members during transfers. The incident involved a resident with multiple diagnoses, including age-related physical debility, contracture of the left knee, and a displaced fracture of the fourth cervical vertebra. The resident's care plan specified the need for assistance with activities of daily living, including transfers, and required the use of a mechanical lift with two staff members present. However, during a transfer, a CNA attempted to use a Hoyer lift alone, causing the resident to experience pain when her leg was pulled. The facility's investigation revealed that the CNA was using the Hoyer lift without a second staff member, contrary to the facility's policy, which mandates at least two trained staff members for safe mechanical lift use. Observations and interviews confirmed that the resident was dependent on transfers and required a mechanical lift with two staff members for safety. The incident was documented in a facility-reported incident and was related to a complaint investigation.
Resident Privacy Violation Due to Unauthorized Social Media Posting
Penalty
Summary
The facility failed to ensure a resident's right to privacy was protected when two photographs of a resident were shared on the facility's social media website without the resident's consent. The resident, who had previously withdrawn permission for her images to be used, was photographed during a solar eclipse and around Easter. These images were later shared on social media, leading to the resident being contacted by a friend who saw the photographs online. The resident had explicitly indicated her refusal to allow her images to be used, as documented in a Photography and Videography Consent Form/Release signed by her. During an interview, the Activity Director acknowledged that the resident had withdrawn her consent and that the images were shared by facility staff without proper authorization. The facility's policy on social media usage clearly states that photographs of residents may only be posted with the resident's knowledge and consent. Despite this policy, the photographs were posted, resulting in a violation of the resident's privacy rights. The images were subsequently removed after the issue was brought to the staff's attention.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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