Rehabilitation Center At Hartsfield Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Munster, Indiana.
- Location
- 503 Otis R Bowen Dr, Munster, Indiana 46321
- CMS Provider Number
- 155662
- Inspections on file
- 26
- Latest survey
- September 15, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Rehabilitation Center At Hartsfield Village during CMS and state inspections, most recent first.
A resident was found with a medication at her bedside without an assessment or physician's order for self-administration. The resident, who was cognitively intact and had multiple diagnoses, indicated the medication was given by a nurse. The ADON confirmed the lack of a self-medication assessment, contrary to the facility's policy.
A resident with a PICC line in the left upper arm did not have the dressing changed as ordered by the physician. The dressing was dated 8/26, and the facility's records lacked documentation of a required change on 9/2. An LPN confirmed the dressing had not been changed since the resident's admission, despite orders to change it weekly. The resident had significant cognitive impairment and required staff assistance.
An LPN failed to don a gown during a PICC dressing change for a resident under Enhanced Barrier Precautions, despite signage and available PPE. The resident had significant cognitive impairment and required staff assistance. The facility's policy required gloves and gowns for high-contact care activities.
The facility failed to conduct self-medication administration assessments for residents with medications at their bedside. Observations revealed that several residents had medications like inhalers, ointments, and glucose tablets in their rooms without proper assessments or physician orders for self-administration. The Assistant Director of Nursing confirmed that no residents were authorized to self-administer medications, highlighting a lapse in medication management procedures.
The facility failed to assess and monitor bruising and skin tears for four residents. A resident had a bruise on her hand that was not documented, despite weekly skin assessments. Another resident had a bruise from an IV insertion that was not recorded. A third resident had multiple bruises and a dressing on his arm without documentation. Lastly, a resident had a skin tear that was not documented, and staff were unaware of it during shift changes. These incidents indicate a lack of proper documentation and monitoring of skin conditions.
A resident's dignity was compromised when their foley catheter bag was left uncovered, allowing urine to be visible from the hallway on multiple occasions. Despite the facility's policy requiring catheter bags to be covered, this standard was not met, as confirmed by the ADON. The resident, who was cognitively intact and had several medical conditions, was observed with the uncovered catheter bag over several days.
Two residents with indwelling Foley catheters were observed with catheter bags and tubing improperly positioned on the floor, contrary to care plans and facility policy. One resident, with a history of sepsis and UTIs, was cognitively intact, while the other, with dementia, required assistance with toileting. Interviews confirmed the catheter care did not meet standards.
A facility failed to administer the correct oxygen flow rate for a resident with respiratory conditions. Despite a physician's order for 4 liters per minute, the resident's oxygen concentrator was consistently set at 3 1/2 liters. This discrepancy was observed over several days, indicating a failure to adhere to the prescribed oxygen therapy.
A resident with heart failure and high blood pressure received Verapamil outside of physician-ordered parameters, as the medication was administered despite systolic blood pressures being below the specified threshold. The MAR showed multiple instances of this non-compliance, and the Assistant DON acknowledged the nursing staff's failure to adhere to the physician's orders.
A facility failed to maintain accurate clinical records for a resident receiving dialysis. The resident's physician's order specified dialysis on certain days with specific times, but progress notes showed different days and times. This inconsistency was confirmed by the ADON, who noted the order had not been updated.
The facility failed to follow infection control practices during a blood sugar check for a resident, as an LPN did not sanitize hands between glove changes. Additionally, a Wound Nurse did not wear an isolation gown while treating a resident on contact precautions for C-Difficile. These actions were against the facility's policies, as confirmed by the ADON.
A facility failed to investigate and resolve grievances from a resident's family member. The resident's husband reported concerns about his wife's care, including being left in bed and missing activities. Despite filing a grievance, he received no written response. The facility's grievance policy requires written outcomes, but this was not followed. The administrator allowed staff to handle grievances without maintaining a log or tracking them, leading to the deficiency.
The facility failed to notify a resident's family of a significant change in condition and subsequent transfer to the hospital. The resident, who had multiple serious diagnoses, was found to be very lethargic and had labored breathing. Despite being assessed and sent to the emergency room, there was no documentation that the family was informed.
The facility failed to provide appropriate social services follow-up related to an outside allegation of exploitation and misappropriation for a resident. The APS representative indicated that they had contacted the assigned facility SW and left detailed voicemails, but received no further communication or documentation. The resident's record showed severe impairments and significant physical dependencies, but there was no social service documentation regarding the allegations or communication with APS. The SW formerly assigned to the resident no longer worked at the facility, and the DON was unaware of the situation.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for the ability to self-administer medications, as evidenced by a medication being left at the bedside. Resident D was observed with a pill in a medication cup on her overbed table, which she identified as Imodium given to her by a nurse. The resident's record showed no assessment for self-administration of medications or a physician's order permitting it. The resident, who was cognitively intact according to a recent mental status assessment, had been admitted with diagnoses including endocarditis, diabetes mellitus, and anemia. The Assistant Director of Nursing confirmed that the resident did not have a self-medication assessment and should not have had any pills in her room. The facility's current pharmaceutical services policy requires that residents with orders for self-administration have medications delivered by a licensed nurse or QMA.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to ensure the timely change of a PICC line dressing for a resident, identified as Resident B, who was admitted with a PICC line in his left upper arm. The dressing was observed to be dated 8/26/24, and the resident's record indicated a physician's order to change the dressing every seven days. However, the September 2024 Treatment Administration Record lacked documentation of a dressing change on 9/2/24, as required. During an interview, LPN 1 confirmed that the dressing had not been changed since the resident's admission on 8/28/24, despite the order and facility protocol requiring a change on admission and weekly thereafter. Resident B had significant cognitive impairment and was dependent on staff for assistance, with diagnoses including osteomyelitis, Parkinson's disease, anemia, and weakness.
Infection Control Breach During PICC Dressing Change
Penalty
Summary
The facility failed to ensure proper infection control measures were implemented during a dressing change for a resident receiving intravenous care. On the specified date, an LPN was observed changing the PICC dressing on a resident's left upper arm while wearing a face mask and gloves but not a gown, despite the requirement for Enhanced Barrier Precautions. A sign on the resident's door indicated that all staff performing direct care were to wear gloves and a gown, and a PPE bin with gowns and masks was available outside the room. The LPN mistakenly believed the sign was for the resident's roommate and acknowledged the error during an interview, subsequently donning a gown. The resident involved had been admitted with diagnoses including osteomyelitis of the vertebrae, Parkinson's disease, anemia, and weakness, and was noted to have significant cognitive impairment, requiring staff assistance for toileting and transfers. A physician's order required the PICC line dressing to be changed every seven days. The facility's policy on the prevention and management of multi-drug resistant organisms specified the use of gloves and gowns for high-contact care activities, such as device care. This incident was related to a complaint investigation.
Failure to Conduct Self-Medication Assessments
Penalty
Summary
The facility failed to ensure that a self-medication administration assessment was completed for residents who had medications at their bedside. This deficiency was observed in four residents during random checks. Resident 6 was found with a Breo inhaler, antibiotic ointment cream, and healing ointment cream on her window sill, but there were no physician orders for these medications or for self-administration. Similarly, Resident 73 had a bottle of Nystatin powder on his nightstand without a self-administration assessment or physician's order to keep the medication at the bedside. Both residents were cognitively intact according to their Minimum Data Set (MDS) assessments. Resident 88, who was not cognitively intact, also had a bottle of Nystatin powder on her dresser without the necessary assessments or orders. Additionally, Resident 82 had glucose tablets and Systane eye drops in her room without a self-medication assessment or physician's order for self-administration. The Assistant Director of Nursing confirmed that no residents on the unit were authorized to self-administer medications, indicating a systemic oversight in medication management and assessment procedures.
Failure to Document and Monitor Skin Conditions
Penalty
Summary
The facility failed to properly assess and monitor areas of bruising and skin tears for four residents. Resident 26 was observed with a reddish-purple discoloration on her right hand, which was not documented in the nursing progress notes or the Medication Administration Record (MAR). Despite weekly skin assessments being signed off, there was no documentation related to the bruising. The Assistant Director of Nursing (ADON) acknowledged that bruises should have been documented when observed. Resident 60 was seen with a light purple discoloration on her right hand, which was also not documented in the nursing progress notes or MAR. The ADON confirmed that bruises should have been documented. Similarly, Resident 168 had multiple areas of discoloration on his arms, with no documentation in the nursing progress notes or MAR. The resident's care plan indicated a risk for complications due to aspirin and antiplatelet therapy, yet there was no order to monitor the bruising or for the dressing on the left upper arm. Resident 6 was observed with a bandaid on her left forearm, which later revealed a skin tear. There was no documentation regarding the skin tear in the nursing progress notes. The ADON was unaware of the skin tear, and the Hospice Nurse mentioned a previous scab on the arm. The RN caring for the resident was not informed of the skin tear during the shift change. These incidents highlight a lack of proper documentation and monitoring of skin conditions, leading to deficiencies in care.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident by not covering the resident's foley catheter bag, allowing urine to be visible from the hallway. This deficiency was observed multiple times over several days, with the resident's catheter bag being uncovered and visible on 5/28/24, 5/29/24, and 5/30/24. The resident, who was cognitively intact and had an indwelling foley catheter due to urinary retention, was observed in bed with the catheter bag hanging on the side of the bed without a dignity cover. The facility's policy, as of 1/1/24, required that drainage bags be covered with a dignity bag, a standard that was not adhered to in this case. The Assistant Director of Nursing confirmed during an interview that the catheter bag should have been covered. The resident's medical history included conditions such as sepsis, high blood pressure, atrial fibrillation, benign prostatic hyperplasia, chronic kidney disease, acute cystitis, and a urinary tract infection, which necessitated the use of a foley catheter.
Improper Foley Catheter Care for Two Residents
Penalty
Summary
The facility failed to ensure proper care for residents with indwelling Foley catheters, as observed in two residents. Resident 73 was repeatedly seen with his Foley catheter bag and tubing in contact with the floor, both while in a wheelchair and in bed. Despite having a care plan that required the catheter bag and tubing to be maintained below bladder level, these observations were made over several days. Resident 73's medical history included sepsis, high blood pressure, atrial fibrillation, benign prostatic hyperplasia, chronic kidney disease, acute cystitis, and a urinary tract infection. The resident was cognitively intact and had a physician's order for a Foley catheter due to urinary retention. Similarly, Resident 93 was observed multiple times with his Foley catheter tubing on the floor while sitting in a wheelchair. This resident had a history of anemia, hypertension, urinary retention, arthritis, dementia, anxiety, and depression, and was dependent on assistance for toileting hygiene. The care plan for Resident 93 also noted the potential for complications related to the urinary catheter. Interviews with the Assistant Directors of Nursing confirmed that the catheter bags and tubing should not have been on the floor, and the facility's policy required securement of the catheter and proper positioning of the collection bag to prevent urine reflux.
Failure to Administer Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that a resident's oxygen was administered at the correct flow rate as prescribed by the physician. Resident 60, who has diagnoses including pneumonia, emphysema, and congestive heart failure, was observed multiple times with an oxygen concentrator set at 3 1/2 liters per minute, despite a physician's order specifying 4 liters per minute. This discrepancy was noted over several days, with observations on 5/28/24, 5/29/24, and 5/30/24, indicating a consistent failure to adhere to the prescribed oxygen therapy. The resident's care plan required oxygen therapy due to multiple respiratory conditions, yet the facility did not comply with the physician's order for the correct oxygen flow rate.
Failure to Follow Physician-Ordered Parameters for Blood Pressure Medication
Penalty
Summary
The facility failed to adhere to physician-ordered parameters for administering blood pressure medication to a resident diagnosed with heart failure, high blood pressure, and anxiety disorder. The resident, who was not cognitively intact for daily decision-making, had a physician's order for Verapamil, a medication used to treat chest pain and lower blood pressure, to be administered at 60 mg twice a day, with instructions to hold the medication if the systolic blood pressure was under 140. However, the Medication Administration Record (MAR) for April and May 2024 showed multiple instances where the medication was administered despite the resident's systolic blood pressure being below the specified threshold. The MAR indicated that Verapamil was given on numerous occasions with systolic blood pressures ranging from 113 to 139, all below the ordered parameter of 140. This occurred on various dates in April and May, demonstrating a pattern of non-compliance with the physician's orders. During an interview, the Assistant Director of Nursing acknowledged that the nursing staff should have followed the physician's orders for administering Verapamil, indicating a lapse in adherence to prescribed medication protocols.
Inaccurate Dialysis Scheduling for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident undergoing dialysis. The resident, who had diagnoses including end-stage renal disease and dependence on renal dialysis, was admitted with a physician's order for hemodialysis at a specific dialysis center on Monday, Wednesday, and Friday, with a pick-up time of 3:00 p.m. and a chair time of 4:00 p.m. However, a progress note indicated that the resident received dialysis on Tuesday, Thursday, and Saturday, with a pick-up time of 12:00 p.m. and a chair time of 1:00 p.m. This discrepancy was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the dialysis order had not been updated.
Infection Control Lapses in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to ensure proper infection control practices during a blood sugar check for Resident 53. An LPN did not sanitize her hands before donning gloves, between glove changes, or after removing gloves while using a glucometer. Although she sanitized her hands before leaving the resident's room, the facility's hand hygiene policy requires hand sanitization after glove removal and before medication administration. This lapse in protocol was confirmed by the Assistant Director of Nursing during an interview. In another incident, the Wound Nurse did not adhere to contact precautions for Resident 73, who was on enteric/contact isolation due to a positive C-Difficile toxin test. The nurse performed a skin treatment without wearing an isolation gown, despite signs indicating the need for such precautions. The resident's medical history included sepsis, high blood pressure, and a urinary tract infection, among other conditions. The Assistant Director of Nursing confirmed that the Wound Nurse should have donned an isolation gown before the treatment, as per the facility's policy on managing multi-drug resistant organisms.
Failure to Investigate and Resolve Grievances
Penalty
Summary
The facility failed to thoroughly investigate and resolve grievances in writing from a resident's family member. Resident B's husband expressed concerns about his wife's care, specifically that she was left in bed for extended periods and missed activities. Despite filing a grievance with the administrator, he did not receive any written response or follow-up regarding his complaint. The facility's grievance policy requires the administrator or a designee to oversee the grievance process and provide written outcomes, but this was not adhered to in this case. Resident B, who was cognitively intact, had multiple diagnoses including hemiplegia, hemiparesis, and other conditions following a cerebral infarction. Her husband repeatedly voiced concerns about her care, including issues with her being left in bed and not receiving showers as requested. Despite these grievances being communicated to the staff and the administrator, there was no documentation of an investigation or resolution provided to the resident or her representative. The administrator indicated that she allowed staff to handle grievances autonomously and did not maintain a grievance log or track grievances. This lack of formal documentation and follow-up is contrary to the facility's grievance policy, which mandates tracking grievances and providing written outcomes. The absence of a formal grievance form and the failure to provide written follow-up contributed to the deficiency identified in the report.
Failure to Notify Family of Change in Resident's Condition
Penalty
Summary
The facility failed to ensure the resident's family was notified of a change in condition for Resident H. Resident H had multiple diagnoses, including sepsis, chronic respiratory failure, and heart failure. On 2/26/24, the resident was noted to be very lethargic and had increased confusion and labored breathing. The Nurse Practitioner (NP) was notified and assessed the resident, who was later found to have a hemoglobin level of 6.9. The resident was subsequently sent to the emergency room for altered mental status and acute kidney injury. However, there was no documentation that the resident's family was notified of these changes or the transfer to the hospital. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the nursing staff were supposed to notify the resident's family at the time of the change in status, but this did not occur. The deficiency was identified during a review of the resident's records and was related to Complaint IN00429419.
Failure to Follow Up on Allegations of Exploitation and Misappropriation
Penalty
Summary
The facility failed to provide appropriate social services follow-up related to an outside allegation of exploitation and misappropriation for a resident by family and facility staff. The Adult Protective Services (APS) representative indicated that they had contacted the assigned facility Social Worker (SW) regarding the resident and left detailed voicemails, but received no further communication or documentation from the SW after an initial call. The APS representative had recommended a psychiatric evaluation and requested documentation for the current healthcare POA, but these were not followed up on by the facility. The record for the resident showed severe impairments in daily decision-making and significant physical dependencies, but there was no social service documentation regarding the allegations or communication with APS in the resident's chart. The SW formerly assigned to the resident no longer worked at the facility, and the Director of Nursing was unaware of the situation. During interviews, the Administrator indicated there were no grievances for the last three months and that unit managers were empowered to handle concerns as they arose. The Social Service Director (SSD) confirmed the lack of documentation regarding the allegations and communication with APS. The deficiency was identified during a complaint investigation and related to the facility's failure to provide medically-related social services to help the resident achieve the highest possible quality of life.
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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